Northern Riverview Health Care, Inc

Inspectors wroteBased on record review and interviews during survey, the facility failed to plan a safe and appropriate discharge for one (1) of two (2) residents (Resident #188) reviewed for discharge. Specifically, Resident #188 was admitted from a group home for individuals with intellectual disabilities and at the facility for short-term rehabilitation following hospitalization. The facility discharged the resident on 12/26/2025, without notice, for a non-emergent diagnostic test and the resident was left at the hospital outpatient department. The facility did not have a plan or date set with the group home for the residents' return. The resident was not cleared by a physician to be safely discharged , and the group home had not evaluated the resident's ability to safely return. [...]

Inspectors wroteBased on observations and interviews conducted during the recertification survey from 03/09/2026 to 03/13/2026, the facility did not store, prepare and serve food in accordance with professional standards for food service safety. Specifically, 1) unlabeled and undated food were stored in the kitchen and unit pantry refrigerators, and 2) expired foods were stored in the kitchen and unit pantry refrigerators.

Inspectors wroteBased on record review and interview conducted during the recertification and abbreviated surveys (485232, 2704152) from 3/09/2026-3/13/2026, the facility did not ensure that the resident's legal representative upon written request, was provided with a copy of the resident's health care record within two (2) working days for one (1) of (2) residents (Resident #188) reviewed for discharge and one (1) of four (4) residents (Resident #74) reviewed for notification of change. Specifically, 1) Resident #74's Health Care Proxy requested health care records on 3/18/2025 and the records were not provided until 6/03/2025; and 2) Resident #188's legal guardian requested health care records on 12/29/2025 and there was no documented evidence the records were provided.

Inspectors wroteBased on observations, record reviews and interviews during the recertification and abbreviated surveys (2625787) from 03/09/2026 through 03/13/2026, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary care and services for 1 of 6 residents (Resident #138) reviewed for Activities of Daily Living. Specifically, Resident #138 was observed eating lunch lying in bed with head in a low position.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 03/09/2026 to 03/13/2026, the facility did not ensure residents received care consistent with professional standards of practice to prevent and promote healing of pressure ulcers for one (1) of six (6) residents (Resident # 14) reviewed for pressure ulcers. Specifically, Registered Nurse #2 did not adhere to the physician orders for the treatment of Resident #14's pressure ulcer by omitting a topical medication and applying a dressing that was not ordered. Findings Include:The facility policy Pressure Ulcer Treatment revised 11/2024, documents to apply dressing/treatment according to the manufacturers direction, care plan and the physician order. Resident #14 had diagnoses of paraplegia, anemia and type 2 diabetes. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification and abbreviated surveys (2702513) from 3/9/2026 to 3/13/2026, the facility did not ensure that each resident received the proper respiratory treatment and care consistent with professional standards of practice for two (2) (Residents #187 and #102) of four (4) residents reviewed for respiratory care. Specifically, 1) the facility did not ensure that a physician's order for continuous positive airway pressure settings and administration parameters was in place for Resident #187 who was reportedly using a continuous positive airway pressure (CPAP) machine; and 2) Resident #102 did not receive the correct flow rate of oxygen therapy based on the physician's order and care plan.

Inspectors wroteBased on observations and interviews conducted during the recertification survey from 03/09/2026 to 03/13/2026, the facility did not ensure daily nurse staffing was posted in an area accessible to all residents and visitors. Specifically, the posting of daily nurse staffing for all nursing staff working in the facility on each shift was not displayed for the date of 03/08/2026.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 03/09/2026 through 03/13/2026, the facility did not ensure proper disposal of garbage and refuse. Specifically, 1) the recycle dumpster had been left open and there were cardboard boxes spilling over the top onto the surrounding ground, and 2) the compactor door had been left open.

Inspectors wroteBased on observations and interviews conducted during the recertification and abbreviated surveys (2625787) from 03/09/2026 to 03/13/2026, the facility did not ensure that essential equipment was maintained in a safe and operating condition for one (1) (Resident #138) of four (4) residents reviewed for the environment. Specifically, Resident #138's bed was broken and could not be inclined beyond 30 degrees.

Inspectors wroteBased on record reviews and interviews conducted during a Abbreviated Survey, the facility did not ensure that all alleged violations including injuries of unknown origin were reported to the Department of Health immediately, but not later than 2 hours after the allegation if the events that caused the allegation result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey agency) in accordance with the State law through established procedures, and report the results of all investigations to other officials (including to the State Survey Agency), within 5 working days of the incident for one (Resident #4) of three Residents reviewed for injury of unknown origin. [...]

Inspectors wroteBased on observations, interviews, and record reviews during an Abbreviated Survey, the facility failed to thoroughly investigate injuries of unknown origin for two(2) of four(4) sampled residents (Residents #1 and #4). Specifically: 1) Resident #1: Following the discovery of a forehead hematoma, the facility failed to provide a completed investigative report. Documentation lacked staff statements from those providing care prior to the injury and failed to include a detailed description of that care. Facility staff could not provide an explanation of how the injury occurred. 2) Resident #4: After an X-ray on 01/21/2026 revealed an acute right tibial plateau fracture, the facility's investigation was incomplete. Missing elements included staff descriptions of care at the time of the incident, details on how the resident was transferred, and a formal investigative conclusion or root cause.

Inspectors wroteBased on observation, record review, and interviews conducted during the Abbreviated Survey (2695368), the facility did not ensure adequate supervision and implementation of an identified intervention for one (Resident #1) of three residents reviewed for injury of unknown origin. Specifically, Resident #1, who resided on a secure unit, required supervision with ambulation and had a history of wandering and falls, was found on 12/10/2025 with a hematoma to the forehead of unknown origin. Following the incident, enhanced monitoring for safety was initiated on 12/10/2025, however, the facility was unable to demonstrate consistent implementation of the enhanced monitoring intervention. The facility provided incomplete enhanced monitoring documentation from 12/15/2025 through 01/10/2026 which contained missing staff signatures and lacked supervisory review.

Inspectors wroteBased on record review and interviews conducted during the Abbreviated Survey (2622688), the facility did not ensure that the resident's family representative was notified of a change in condition for one (Resident #1) of three residents reviewed for notification of changes. Specifically, on 08/29/2025, Resident #1's family representative observed redness to Resident #1's right eye. The Family representative reported the observation to facility staff and was informed that the redness was due to an allergic reaction to medication the issue had already been addressed by the physician. There was no documented evidence that nursing staff identified or assessed the redness prior to the family representative' observation. There was no documented evidence that the resident's representatives were notified of the change in condition prior to the report from the family representative.

Inspectors wroteBased on record review and interviews conducted during the Abbreviated Survey (2622688), the facility did not ensure that all alleged violations involving abuse and neglect are reported not immediately but not later than 2 hours after the allegation is made if the events that caused the allegation involve abuse or results in serious bodily injury, or not later than 24hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials including the State Survey Agency for one (1) resident (Resident #1) of three (3) reviewed for abuse. Specifically, on 09/12/2025, Resident #1's family representative informed the facility that Resident #1 had been punched in the face by another resident. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (2622688), the facility did not report to the State Agency an alleged violation of abuse against a resident who is receiving care from the facility no later than 24hours if the events that cause the suspicion did not result in serious bodily injury for one(1) Resident #1 of three (3) residents reviewed for abuse. Specifically, on 09/12/2025, Resident #1's family representative informed the facility that Resident #1 was punched in the face by a peer. The facility's investigation form and progress notes revealed the report from the family representative was received on 09/12/2025 receiving the information from the family representative. The Facility provided documentation of an investigation initiated on 9/17/2025. [...]

Inspectors wroteBased on record review and staff interviews conducted during the Abbreviated Survey (2622688), the facility did not ensure that Resident #1's Comprehensive Care Plan was revised to include measurable, resident-specific interventions specifically reflecting a change in condition involving right-eye redness that resulted in the initiation of antibiotic eye drops. Specifically, Ciprofloxacin(antibiotic) ophthalmic drops were ordered on 08/29/2025 and initiated on 08/30/2025 for the resident's right-eye redness. The Comprehensive Care Plan was not revised to include interventions related to the new treatment and the change in condition. Resident #1's comprehensive care plan interventions was last update 01/23/2025 which addressed a prior influenza related infection. There was no documented evidence of the current condition reported on 08/29/2025.

Inspectors wroteBased on observations, record review, and interviews conducted during the Abbreviated Survey (# 2622688), 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 #1) of three (3) residents reviewed for abuse. Specifically, on 08/29/2025, Resident #1's family representative reported redness to Resident #1's right eye to nursing staff. The family representative stated that nursing staff told them the condition was already addressed. Record review revealed was no documented nursing assessment, a change-in-condition evaluation or a physician notification. There was no documentation that staff identified the redness prior to the family representative report. [...]

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (2622688), the facility did not ensure physician supervision oversight of medical care for one (Resident #1) of (3) three residents reviewed for physician services. Specifically, an order for ciprofloxacin(antibiotic) eye drops was ordered for Resident #1's right eye on 08/29/2025 after redness was reported by family representative. There was no documented physician assessment or nursing assessment at the time the order was entered. The treatment began 08/30/2025, and Resident #1 was not evaluated by a medical provider until 09/04/2025 six days after the change in condition was identified and after treatment had already been initiated.

Inspectors wroteBased on record reviews and interviews during an abbreviated survey (NY00355946, NY00334577, NY00336626), the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility also did not report the results of all investigations to the New York State Department of Health in accordance with State law, within 5 working days of the incident for 3 out of 3 residents (Resident #1, Resident #3, Resident #5) reviewed for abuse. [...]

Inspectors wroteBased on record reviews and interviews during an abbreviated survey (NY00355946, NY00334577), the facility did not ensure the comprehensive care plan was updated and revised for 3 out of 3 residents (Resident #1, Resident #3, Resident #4) reviewed for care planning. Specifically, (1) On 9/27/2024 Resident #1 reported to their representative that they were beaten on 9/26/2024 by staff in the dining room. Review of Resident #1's abuse care plan revealed it was not updated to reflect the allegation of abuse (2) On 3/26/2024 Resident #4 exposed themself to Resident #3. Resident #3's abuse care plan was not updated to reflect this allegation and Resident #4's behavior care plan was not updated to reflect their behavior.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00373143, NY00352914), the facility did not ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal care for 2 out of 3 residents (Resident #2, Resident #7) reviewed for activities of daily living. Specifically, (1) Resident #2 had a known history of bladder and bowel incontinence and was dependent for toileting. Review of Resident #2's Certified Nurse Assistant documentation for June 2024 revealed the bladder and bowel incontinence care was not signed by direct care staff was not provided on 5 occasions. Review of Resident #2's Certified Nurse Assistant documentation for July 2024 revealed the bladder and bowel incontinence care was not signed by direct care staff,on 7 occasions; [...]

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00373143) the facility did not ensure that sufficient nursing staff was consistent for residents according to the daily staffing needs. Certified nurse aide staff levels were frequently below the levels determined by the facility to be necessary to meet the needs of the residents. Specifically, review of the facility daily staffing sheets for July 2024 and August 2024 revealed staffing was not adequate across various shifts, on the first floor, based on the unit needs and provider average ratio levels documented in the facility assessment.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00334577) the facility did not ensure the residents right to a dignified existence inside the facility for 1 out of 3 residents (Resident #3) reviewed for dignity. Specifically, on 2/26/2024 Resident #4 who was Resident #3's neighbor, went to Resident #3's room unzipped their pants and exposed themself to Resident #3. Resident #3 was upset and crying about Resident #4's behavior.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00334577), the facility did not ensure the residents right to be free from abuse for 1 out of 3 residents (Resident #3) reviewed for abuse. Specifically, on 2/26/2024 Resident #4, who was Resident #3's neighbor, went to Resident #3's room unzipped their pants and exposed themself to Resident #3. Resident #3 was upset and was crying about Resident #4's behavior and verbalized a fear of being raped. Subsequently, Resident #3's room was changed to another unit.

Inspectors wroteBased on observation, interview and record review conducted during the recertification and abbreviated surveys (NY00328066) from 2/12/24 to 2/27/24, 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 confidential interviews and the group meeting that the facility was short staffed at times especially at night and on the weekends, there was a lack of timely staff response to call bells, and some stated that they smelled urine odors, 2) multiple nursing staff members reported a lack of sufficient staffing; and 3) analysis of the actual staffing schedule showed that on multiple occasions from January 13, 2024 through February 15, 2024, the facility was below the minimum levels documented on the Facility Assessment.

Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey from 2/12/24 to 2/27/24, the facility did not ensure that each resident was screened for a mental disorder (MD) or intellectual disability (ID). This was evident for 5 of 35 residents reviewed. Specially, Residents #34, #151, #105, #79, and #117 did not have the required pre-admission screening and resident review assessment completed prior to their admission to the facility.

Inspectors wroteBased on record reviews and interviews during the Recertification Survey from 2/12/24 to 2/27/24, the facility did not ensure that Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, performance evaluations were not conducted every 12 months for 9 of 10 Certified Nurse Aides (Staff #13, 14, 15,16,16, 38, 39, 40, and 41) records reviewed.

Inspectors wroteBased on observation, interview and record review during a recertification survey from 2/12/24 to 2/27/24, the facility did not ensure that they store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were baking sheets on the floor in the kitchen, garbage was placed on top of a cart next to a pan storage rack with a whisk touching the garbage bags, thermometers used for food thermometers were not sanitized properly, sanitizer logs were not completed, a dining room resident refrigerator, freezer thermometer, was not working and resident's personal food items were not dated and labeled appropriately.

Inspectors wroteBased on record review and interview during the recertification survey 2/12/24 to 2/27/24, the facility did not ensure each resident was offered influenza and/or pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 4 (Residents #63, #96, #165 and #168) of 5 residents reviewed. Specifically, the facility did not ensure, Resident #63 was screened properly for influenza immunization, and/or Residents #96, #165, and #168 were screened for eligibility, offered and educated about pneumococcal immunizations. This was evidenced by: [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 2/12/24 to 2/27/24, it was determined for 1 of 7 residents (Resident #151) reviewed for dignity, the facility did not ensure all residents had the right to a dignified existence. Specifically, Resident #151 reported Staff #35 (Certified Nurse Aide) spoke to her in a derogatory manner on more than one occasion and Staff #35 was observed stating please to Resident #151 after Resident #151 made two requests for ice.

Inspectors wroteBased on observation, record review and interview during a recertification survey from 2/12/24 to 2/27/24, the facility did not ensure residents rights to a safe, comfortable, home-like environment for 1 of 4 residents (Resident #114) observed during dining. Specifically, Resident #114 was not provided an overbed table and was observed eating their lunch meal which was placed on a chair in their room. On another occasion, the resident was observed lying in bed and staff placed the resident's food tray on their bed by their feet.

Inspectors wroteBased on observations, record review and interview during the recertification and abbreviated surveys (NY00330459) from 2/12/24 to 2/27/24, the facility did not ensure that all alleged violations involving abuse and neglect were reported and/or reported timely to The New York State Department of Health for 2 of 3 residents reviewed for abuse and/or misappropriation (Residents #129 and #156). Specifically, 1) the facility did notify the New York State Dept of Health when Resident #80 pushed Resident #129 to the floor resulting in Resident #129 hitting their head requiring medical evaluation; and (2) the facility did not notify the New York State Department of Health timely when Resident #156's wallet and cell phone were stolen.

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 2/12/24 to 2/27/24, the facility did not notify the ombudsman for 1 of 2 residents (Resident # 105) reviewed for hospitalization. Specifically, the resident was transferred to the hospital and the facility could not provide evidence that notification was sent to the ombudsman.

Inspectors wroteBased on observations record review and interviews, during the recertification survey from 2/12/24 to 2/27/24, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1 of 4 residents reviewed for accidents. Specifically, Resident #129 was involeved in a resident-to-resident altercation on 1/25/24 and the Behavior and Abuse Care Plans were not revised and/or updated to reflect new interventions to prevent reoccurrences.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification and Abbreviated surveys (NY00320687) from 2/12/24 to 2/27/24, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice for 1 of 2 residents (Resident #64) reviewed for antibiotic use. Specifically, Resident #64 did not receive intravenous antibiotic medication Meropenem as ordered by the medical provider at 12 AM, 6 AM, 12 PM and 6 PM on 7/22/2023 and the medical provider was not notified.

Inspectors wroteBased on observation, record review and interview during a recertification survey from 2/12/24 to 2/27/24, the facility did not ensure that each resident received adequate supervision and that the environment remained as free from accidents as possible for 1 out of 4 residents (Resident #114) observed during dining. Specifically, supervision during meal intake was not provided as per care plan and staff did not ensure the resindent remained upright for 30 minutes after meals as per speech pathologist recommendation for Resident #114 with aspiration precautions.

Inspectors wroteBased on interview and record review during the recertification survey conducted 2/12/24 to 2/27/24, the facility did not ensure each resident was offered the COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 2 of 5 residents (Resident #165, #168) reviewed for infection control. Specifically, there was no documented evidence Resident #165, #168 was offered, declined, and/or were educated about the COVID-19 vaccination.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated surveys (NY00324940 and NY00295143) from 2/12/24 to 2/27/24, it was determined for 2 of 5 residents (Residents # 274 and 224) reviewed for personal property, the facility did not ensure grievances were resolved in a timely manner. Specifically, the facility lacked documentation of the completion of a thorough investigation and timely resolution of the residents' reports of missing chains with pendants.

Inspectors wroteBased on record reviews and interview during recertification and abbreviated surveys (NY00321475) from 2/12/24 to 2/27/24, the facility did not ensure a resident who was unable to carry out activities of daily living received services and assistance to maintain good personal hygiene for 1 out of 9 residents (Resident #234) reviewed for activities of daily living. Specifically, there was no documented evidence that colostomy care, bed baths, hoyer lift transfer and bladder incontinence care were consistently provided for Resident #234 as per physician order and/or the comprehensive care plan.

Inspectors wroteBased on observation, interview and record review during a recertification and an abbreviated survey (NY00259391) conducted from 10/19/2020 through 10/26/2020 it could not be ensured that the facility reported timely or thoroughly investigated all alleged violations involving abuse, neglect or mistreatment for 1 of 2 residents (Resident #118) reviewed. Specifically, Resident #118 sustained a laceration on his right hand after an interaction with a staff member. Supporting evidence to rule out abuse/neglect or evidence confirming that the incident was reported timely to the New York State Department of Health (NYSDOH) was not available for review despite several requests.

Inspectors wroteBased on record review and interview during a recertification survey it could not be ensured that the facility notified all residents or the residents' representative(s) of a transfer or discharge and the reasons for the move in writing and in a language and manner they understand. This was evident for 1 of 2 (Resident #140) residents reviewed for Hospitalization.

Inspectors wroteBased on record review and interview during a recertification survey, it cannot be ensured that the facility provided written notice of the facility's Bed Hold policy upon transfer to all residents or residents' representative(s). This was evident for 1 of 2 residents (Resident #140) reviewed for Hospitalization. The facility policy and procedure titled Bed Hold dated 3/2018 and revised 7/2019, documents the facility will provide written information regarding the bed-hold and return policy upon admission and prior to/at the time of hospitalizations or therapeutic leaves as soon as practicable following an emergency transfer.

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, it could not be ensured that the facility provided the appropriate treatment and services to improve and /or prevent further decline in range of motion (ROM). Specifically, 1 of 4 residents (Resident # 29) reviewed for limited Range of Motion (ROM) did not have bilateral hand rolls in place to prevent further joint contracture as ordered by the physician.

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey it could not be ensured that the facility staff followed proper hand hygiene and gloving techniques to prevent cross contamination and the spread of infection for 2 of 3 residents (Residents #113 and #115) reviewed for pressure ulcers. Specifically, 1) cross contamination of wound/wound supplies was observed during dressing change and 2) hand hygiene after removal of used gloves was not observed during wound care.