Adira at Riverside Rehabilitation and Nursing

Inspectors wroteBased on observations, interviews, and record review conducted during the abbreviated survey, the facility did not ensure residents received quality care for two (2) (Residents #1 and #6) of five (5) residents reviewed for pressure ulcers. Specifically, 1) Resident #6 was ordered to receive wound treatment more frequently than recommended by the wound care specialist, 2) wound care specialist findings and recommendations for Resident #1 were not accurately transcribed and signs of worsening infection were not thoroughly reviewed and addressed.

Inspectors wroteBased on observations, interviews, and record review conducted during an abbreviated survey, the facility did not ensure residents with pressure ulcers received treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing in two (Residents #1 and #3) of five residents reviewed for pressure ulcers. Specifically, there was no documented evidence Resident #1's treatment plan was revised to address stagnant wound progress and serosanguinous ulcer drainage for multiple weeks, and 2) Resident #3 was admitted to the facility at risk for skin breakdown and there was no documented evidence they received devices and repositioning to prevent the development of six new pressure injuries.

Inspectors wroteBased on observations, interviews, and record review conducted during an abbreviated survey, the facility did not ensure the physician reviewed the resident's total program of care, including medications and treatments, at each visit for two (Residents #6 and #1) of four ventilator-dependent residents sampled. Specifically, 1) discrepancies in the wound specialist's and the attending physician's ordered treatments were not addressed during physician visits, and 2) there was no evidence the attending physician reviewed labs reporting increasingly abnormal values and wound notes reporting stagnant, unhealing wounds with ongoing drainage.

Inspectors wroteBased on observations, interviews, and record review conducted during an abbreviated survey, the facility did not ensure services provided by the facility met professional standards of quality for two (Residents #1 and #6) of five residents sampled for pressure ulcer review. Specifically, 1) Wound Care Nurse #2 transcribed treatment orders received from the Wound care Physician for Resident #6 to occur more frequently than recommended 2) Wound Care Nurse #2 made changes to treatment orders for Resident #1 that were not recommended by the wound care specialist.

Inspectors wroteBased on observations, interviews, and record review conducted during an abbreviated survey, the facility did not ensure infection prevention and control standards were maintained during wound care to prevent the spread of infection to other wounds for 1 (Resident #6) of 2 residents observed for wound care. Specifically, Resident #6's uncovered back and buttock wounds were observed having direct contact with a towel soaked with purulent drainage from soiled dressings removed from the resident's infected right buttock ulcer.

Inspectors wroteBased on record review and interview conducted during the abbreviated survey (2581942), the facility failed to ensure all residents were free of accident hazards and that each resident received assistance to prevent falls for one (1) (Resident #1) of three (3) residents reviewed for accidents. Specifically, Resident #1 sustained a head injury after a fall from their bed on 08/05/2025. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.

Inspectors wroteBased on interview, observation and record review during a Recertification Survey conducted from 8/26/2024 through 8/30/2024, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and to prevent the development of pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable. This was evident for 1 of 4 residents reviewed for pressure ulcers (Resident #24). Specifically, Resident #24 was assessed as high risk for pressure ulcers and was identified to have left heel redness on 08/24/2024. The resident's care plan and interventions were not promptly updated and implemented to prevent further deterioration of the left heel skin integrity. [...]

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey from 8/26/24 through 8/30/24 the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) multiple residents reported during interviews and the Resident Council Group meeting that the facility was short staffed at times, and this resulted in call bells not being answered timely and residents not getting out of bed; 2) several nursing staff members reported a lack of sufficient staffing; and 3) an analysis of the actual staffing schedule showed that on multiple occasions from 7/25/24 to 8/25/24, the facility was below the minimum levels documented on the Facility Assessment.

Inspectors wroteBased on staff interview and review of facility records during the recertification survey from 8/26/24 through 8/30/24, the facility did not ensure Certified Nurse Aides (CNAs) performance reviews were completed at least once every 12 months. Specifically, eight of eight randomly selected certified nurse aides (CNAs) (#3, #6, #14, #16, #17, #18, #19 and #20) did not have a performance review documented at least once every 12 months.

Inspectors wroteBased on record reviews and interviews during the recertification and abbreviated survey (NY00325832) from 8/26/24 to 8/30/24 , the facility did not ensure that a resident's representative was promptly notified of a change in ins status For 1 of 28 residents (Resident #38) reviewed for notification of change. Specifically, Resident #38's designated representative was not made aware the resident had pneumonia and antibiotic was initiated.

Inspectors wroteBased on observations record review and interviews, during the recertification survey from 8/25/24 to 8/30/24, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner to reflect the resident's changing needs and current status as evidenced by 1 of 4 residents (Resident #24) reviewed for skin impairments. Specifically, Resident #24 acquired a pressure injury on the left heel and the care plan was not updated with goals and interventions to promote wound healing.

Inspectors wroteBased on observation, record review and staff interviews during the recertification survey from 8/26/24-8/30/24, the facility did not ensure that needed services, care and equipment were provided to assure that residents with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for 3 of 3 residents (Residents # 24, #54 and #91) reviewed for position and mobility. Specifically, Residents #24, #54, and #91 were care planned for hand rolls and were observed on multiple occasions without their hand rolls.

Inspectors wroteBased on observation, record review and interviews during the recertification survey from 8/26/2024 to 8/30/2024, the facility did not ensure that each resident received necessary respiratory care including oxygen therapy that was in accordance with professional standards of practice and as ordered by the practitioner for 1 (Resident #308) of 4 residents reviewed for respiratory care. Specifically, for the Resident #308, the facility did not ensure the physician's order for the prescribed oxygen administration was followed.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey and Abbreviated Survey (NY00336677) from (8/26-8/30/24), the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety and food prep equipment was clean and in safe operating condition. Specifically, 1) the walk-in refrigerator contained expired peanut butter and jelly sandwiches, and expired egg salad and peanut butter and jelly sandwiches were observed on prepared lunch trays, 2) Resident's personal food was observed in the resident pantry refrigerator beyond its 3 day limit; and 3) the first floor resident ice machine was not clean and observed with black slime on the inside of the machine which was in close contact with ice cubes.

Inspectors wroteBased on observations, record review, and interviews during a Recertification Survey (8/26/24-8/30/24), the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, 1) the facility did not ensure that an infection surveillance plan based on facility assessment was implemented for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks. 2) the facility Water Management Plan for Legionella had not been reviewed annually, 3) the facility did not ensure that 9 of 10 staff members were offered and educated regarding the risks and benefits of the pneumonia vaccination and given the opportunity to decline or receive the vaccination; and 4) did not properly implement Enhanced Barrier Precautions for 4 of 24 residents ( #6,#307,#309 and #24).

Inspectors wroteBased on record review and interview during the recertification survey conducted 08/26/24 to 08/30/24, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Residents #91) reviewed. Specifically, there was no documented evidence Resident #91 was offered, declined, or educated on the pneumococcal immunization.

Inspectors wroteBased on interview and record review during the recertification survey conducted 08/26/24-8/30/24, the facility did not ensure each staff and resident was screened, offered the COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 1 of 5 residents and 1 of 10 staff reviewed for COVID vaccines. Specifically, there was no documented evidence of immunization records for COVID vaccines for Resident #91 and Staff #37.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00322720), the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accident hazards as possible for 1 of 3 residents (Resident #1) reviewed. Specifically, on 08/24/2023 Certified Nursing Assistant (CNA#5) provided care to Resident #1 who required 2-person assistance for toileting and bed mobility, by themselves without assistance. Resident #1 rolled out of bed and fell sustaining a right tibia and fibula (shin/calf bone) fracture.

Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that a dignified experience was maintained forn 2 of 4 residents reviewed for dignity. Specifically, Resident #63 was exposed beyond a wound area during wound care and Resident #10 medical record was visible to hallway traffic during a medication pass.

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, the facility did not ensure that a resident received scheduled showers. Specifically, one of three residents (Resident # 63) reviewed for activities of daily living (ADLs) did not receive twice weekly showers as scheduled.

Inspectors wroteBased on observation, interview, and record review, conducted during a recertification survey, the facility did not ensure that a resident with bowel irregularity was given bowel medication for constipation problems. Specifically, 1) one of one resident (Resident #63) reviewed for constipation was not given bowel medication according to the facility Bowel Protocol for absence of bowel movement that exceeded three days; 2) the resident's bowel movements were not consistently documented on the scheduled dates to indicate accurate, and consistent bowel movements.

Inspectors wroteBased on observation, interview, and record review, conducted during a recertification survey, the facility did not ensure that facility staff followed proper hand hygiene and gloving technique to prevent cross contamination and the spread of infection. Specifically, (1) cross contamination of wounds and wound supplies was observed; and (2) removal of soiled gloves and hand hygiene were not observed during wound care procedures for 3 of 7 residents (Residents #63, #39, and #11) reviewed for pressure ulcer/injury.

Inspectors wroteBased on observation, documentation review and staff interview, the facility did not ensure that the physical environment was maintained in accordance with 483.90. Specifically, several gnats were noted in the kitchen and on a resident floor. This was noted on 1 of 3 resident floors. During the recertification survey on 8/09/21 and 8/10/21 between the hours of 9:30 AM to 2:00 PM, a tour of the kitchen was conducted. Several gnats were noted by the pot washing station and near the refrigerators. Gnats were also noted on the nursing unit on the lower level during the Life safety tour of the facility. In an interview with the Dietary Director on 8/9/21 at approximately 9:40 AM, the Dietary Director stated that the gnats come in through the window. The Dietary Director further stated that bleach is poured down the sewage pipe to reduce their activity. [...]

Inspectors wroteBased on interview and record review conducted during the most recent recertification survey, the facility did not ensure that the plan of care was implemented consistently to address pre-dialysis assessments for 1 resident (Resident #47) reviewed for dialysis and for 1 of 3 residents (Resident #11) reviewed for activities of daily living (ADLs). Additionally, the plan of care for Resident # 47 did not address post dialysis assessments.