New Riverdale Rehab and Nursing

Inspectors wroteBased on record review and interview during the Recertification and Complaint (NY00371559) Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that residents were free from abuse, neglect, and exploitation. This was evident in two (2) (Residents #242 and #117) of two (2) residents reviewed for abuse out of 31 total sampled residents. Specifically, Resident #242 who had history of physically abusive behavior and physical altercations with other residents, was not provided adequate supervision and monitoring despite staff being aware of Resident #242's behavior. Subsequently, on 02/08/2025 at approximately 12:30 PM, Resident #242 punched Resident #117 in the head while both residents were in the bathroom. Resident #117 sustained laceration to the left eyebrow area that required emergency medical intervention. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that a resident's right to a safe, clean, comfortable, and homelike environment was maintained. This was evident in 1 (Unit 3) of 3 resident units. Specifically, residents' rooms were not cleaned, had broken appliance and furniture, and chipped paint.

Inspectors wroteBased on record review and interviews during the Recertification and Complaint (NY00371559 and NY00372528) Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment including injuries of unknown origin are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to the State survey agency. This was evident in 5 (Residents #25, #36, #93, #117 and #242) of 31 total sampled residents. Specifically, 1.) On 02/14/2025 at approximately 4:00 PM, Resident #25 reported that the Certified Nursing Assistant assigned to them the night before was too rough. This alleged abuse incident was not reported to the New York State Department of Health. 2.) On 02/04/2025, Resident #93 was observed with right eyelid swelling and dark discoloration. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that a resident's comprehensive care plan was reviewed and revised by the interdisciplinary team based on a resident's changing needs, goals, and in response to current interventions. This was evident in 1 (Resident #40) of 31 sampled residents. Specifically, Resident #40's comprehensive care plan was not reviewed and revised after each incident of non-compliance with the smoking policy.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that it promoted and facilitated a resident's right to self-determination through support of resident's choice. This was evident in 1 (Resident #5) of 1 resident reviewed for Choices out of 31 total sampled residents. Specifically, Resident #5's bathing preference was not honored.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that a comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident in 1 (Resident #36) of 3 residents reviewed for care planning out of 31 total sampled residents. Specifically, Resident #36 had no comprehensive care plan developed to address at risk for abuse.

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that the services provided or arranged by the facility as outlined by the comprehensive care plan, met professional standards of quality. This was evident in 1 (Resident #39) of 5 residents reviewed for Unnecessary Medications and Medication Regimen Review. Specifically, serum depakote level was ordered for Resident #39 on 02/12/2025. There was no documented evidence that the serum level was obtained. Cross Reference: F756 Drug Regimen Review, Report Irregular, Act on F711 Physician Visits - Review Care/notes/order

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that a resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. This was evident in 1 (Resident #122) of 5 residents reviewed for nutrition. Specifically, Resident #122 had significant weight loss of greater than 7.5 % in the last 3 months from November 2024 through February 2025 with no proactive interventions.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was evident in 1 (Resident #39) of 5 residents reviewed for Unnecessary Medications and Medication Regimen Review. Specifically, the Nurse Practitioner failed to follow up on the results of a serum Depakote level ordered on 02/12/2025. Cross Reference: F756 Drug Regimen Review, Report Irregular, Act on F658 Services Meet Professional Standards

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility failed to address an irregularity identified during Drug Regimen Review to minimize or prevent adverse consequences. This was evident in 1 Resident (Resident #39) of 5 residents reviewed for Unnecessary Medications and Medication Regimen Review. Specifically, on 02/11/2025, the pharmacy consultant recommended Depakote serum level for Resident #39. There was no evidence that the serum level has been obtained.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that the results of the most recent survey was posted in a place readily accessible to residents, visitors, or legal representatives of residents. Additionally, there was no posted notice of availability of such reports in areas of the facility that are prominent and accessible to the public. Specifically, the facility's survey results were located in a binder inside the security office.

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification and abbreviated survey (NY00315600, NY00316068) from 6/13/23 to 6/21/23, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours, to the New York State Department of Health (NYSDOH). This was evident for 4 (Resident #43, Resident #92, Resident #99 and Resident #117) of 4 reviewed for abuse out of 27 sampled residents. Specifically, 1) the facility did not report an allegation of resident to resident abuse involving Resident #43 and Resident #117 to the NYSDOH within 2 hours. 2) the facility did not report an allegation of resident to resident abuse involving Resident #92 and Resident #99 to the NYSDOH within 2 hours.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 06/13/2023 to 0 6/21/2023, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within 14 days of completion. This was evident for 24 (Resident #s 57, 90, 70, 88, 115, 75, 10, 128, 45, 7, 53, 2, 67, 15, 102, 18, 30, 111, 94, 58, 3, 36, 81, 116) of 25 residents reviewed for Resident Assessment. Specifically, MDS assessments for Resident #s 57, 90, 70, 88, 115, 75, 10, 128, 45, 7, 53, 2, 67, 15, 102, 18, 30, 111, 94, 58, 3, 36, 81, and 116 were not transmitted and submitted to QIES within 14 days of their completion date.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 6/13/23 to 6/21/23, the facility did not ensure residents were cared for in a manner that maintained or enhanced their dignity. This was evident for 1 (Resident #46) of 25 total sampled residents. Specifically, Resident #46 was observed with their Foley Catheter (FC) bag uncovered and exposed to public view.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey from 6/13/23 to 6/21/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 2 Units (Unit 1 and Unit 3) of 3 Units. Specifically, 1) Unit 1 was observed with missing window blind blades, window sills dusty and with tape 2) Unit 3 was observed with walls with mismatching paint, plaster, mismatching floor tiles, and radiator cover that was dirty and in disrepair.

Inspectors wroteBased on observation, interviews and record review conducted during the recertification and complaint survey (NY00303941) from 6/13/23 to 6/21/23, the facility did not ensure that resident's environment was free from accident hazards. This was evident for 1 (Resident #340) of 4 reviewed for Accidents out of 27 total sampled residents. Specifically, Resident #340 who was severely cognitively impaired and had a history of removing Wander Alert Device (WAD) was able to bypass locked system to the basement level via elevator and exited the facility undetected through a broken emergency exit door.

Inspectors wroteBased on observations, record review and interviews conducted during a Recertification survey, the facility did not ensure that a clean, comfortable, and homelike environment was provided to residents. Specifically, resident rooms were not maintained in good repair and in a homelike manner. This was observed during Environmental Observations on 1 of 3 resident units. (Unit 2)

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey, the facility did not ensure garbage and refuse was disposed of properly. Specifically, the garbage compactor door was observed to be opened on multiple occasions. This was evident for 1 of 2 garbage compactors. The finding is: The facility policy and procedure titled, Waste Disposal dated 9/8/2020 documented that all garbage containers must be covered with tight fitting lid or cover. On 04/26/2021 at 10:00 AM, one of three doors on one of two garbage compactors was observed to be opened. There were clear plastic bags with garbage lying in the immediate area. On multiple occasions on 04/26/2021, 04/27/2021,04/28/2021, and 04/29/2021, the garbage compactor was observed with the same compactor door opened with clear plastic bags with garbage visible. [...]

Inspectors wroteBased on interviews and record review conducted during a recertification survey, the facility did not ensure that appropriate notices were provided to residents being discharged from skilled services. Specifically, the facility did not issue an Advance Beneficiary Notice (ABN) to a resident planning to remain in the facility. This was evident for 1 of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification out of a total sample of 28 (Residents #129).

Inspectors wroteBased on record review and staff interview conducted during the Recertification survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed to address resident's concerns. Specifically, there was no documented evidence that the comprehensive care plan included measurable goals, objectives, and interventions to address a resident with hearing impairment. This was evident for 1 of 4 residents reviewed for Communication/Sensory out of a sample of 28 residents. (Resident #71)

Inspectors wroteBased on observations, record reviews and interviews conducted during the Recertification Survey, the facility did not ensure that residents received proper treatment and assistive devices to maintain hearing abilities. Specifically, a resident with hearing impairment did not receive audiology follow-up or assistive devices. This was evident for 1 of 4 residents reviewed for Communication/Sensory out of a sample of 28 residents. (Resident #71)

Inspectors wroteBased on observations, record reviews and interviews conducted during the Recertification Survey, did not ensure that the physician reviewed the resident's total program of care at each visit. at each visit. Specifically, services and care for a resident with hearing impairment was not reviewed and followed up on at each visit. This was evident for 1 of 4 residents reviewed for Communication/Sensory out of a sample of 28 residents. (Resident #71)