River View Rehabilitation and Nursing Care Center

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00382934), the facility did not ensure residents had the right to be free from abuse for one (1) of three (3) residents reviewed (Resident #1). Specifically, on 06/08/2025, Registered Nurse Supervisor #1 held Resident #1 around their neck while yelling at them, causing the resident physical pain and mental anguish. This resulted in actual harm, past non-compliance, to Resident #1 that was not Immediate Jeopardy. The facility policy Abuse and Neglect, revised 01/2023, documented the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment which results in physical harm, pain or mental anguish. An example of abuse included, but was not limited to, rough handling during care. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 11/12/2024-11/15/2024, the facility did not ensure a resident's right to personal privacy of accommodations, medical care, and personal care for 50 of 77 residents reviewed. Specifically, all resident rooms were equipped with individual monitoring devices which currently transmitted personal health information to a third-party company and the facility did not obtain resident or resident representative consent for monitoring.

Inspectors wroteBased on record review, observations, and interviews during the recertification and abbreviated (NY00354914) surveys conducted 11/12/2024-11/15/2024, the facility did not ensure planned menus were followed for 3 of 3 residents (Residents #2, #32, and #528) reviewed. Specifically, Residents #2, #32, #528 did not receive preferred food items as planned per their individualized meal tickets.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 11/12/2024-11/15/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, in the main kitchen there were unclean areas, potentially hazardous foods were not cooled properly, food storage of cold foods was not maintained, and there was lack of proper hand hygiene during meal service.

Inspectors wroteBased on observations and interviews during the recertification and abbreviated (NY00354914) surveys conducted 11/12/2024-11/15/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 3 meal test trays (the 11/13/2024 and 11/14/2024 lunch meals) reviewed; for 11 of 11 anonymous residents present at the Resident Council meeting; and for one additional resident (Resident #2) interviewed during initial screening. Specifically, the 11/13/2024 and 11/14/2024 lunch meals were not served at palatable and appetizing temperatures and were burnt and not flavorful; 11 residents at the Resident Council meeting stated the food was cold and did not look appetizing; and Resident #2 stated the food was bland and cold.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 11/12/2024-11/15/2024, the facility did not ensure the Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration, all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) was explained to the resident and their representative in a form and manner they understood, including the ability to rescind the agreement in 30 days, and the right to communicate with surveyors, state and federal officials, and the Ombudsman for 1 of 3 residents (Resident #63) reviewed. [...]

Inspectors wroteBased on observation and interview during the recertification survey conducted 11/12/2024-11/15/2024, the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in one resident room and one medication room. Specifically, the second-floor medication room was in disrepair and resident room [ROOM NUMBER] had an unclean floor.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 11/12/2024-11/15/2024, the facility did not ensure the results of the most recent Federal and State survey was posted in a place readily accessible where individuals wishing to examine the survey results did not have to ask for them. Specifically, the most recent survey results and plan of correction were located above the front desk and were not readily accessible. Additionally, the facility did not post notice of the availability of survey results in areas of the facility that were prominent and accessible to the public. Findings Include: The undated Resident Orientation Handbook documented the yearly survey results were in the front lobby. During the Resident Council Meeting on 11/12/2024 at 1:46 PM, 11 anonymous residents stated they did not know the location of the previous survey results. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00287791 and NY00287951) surveys conducted 10/11/22-10/14/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 2 residents (Resident #33) reviewed. Specifically, Resident # 33 had a significant weight loss, was not reassessed by clinical nutrition staff, and had further significant weight loss.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 10/11/22-10/14/22, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for 1 of 2 medication carts (Unit 2 East side) and 2 of 2 medication storage rooms (Units 1 and 2) observed. Specifically, Unit 2 had expired stock medications in the unit medication room and the East side medication cart. Additionally, the Unit 1 medication room refrigerator had a multi-dose vial opened greater than 30 days.

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 3 of 4 meals (breakfast, lunch, dinner) tested for palatability and temperature. Specifically, items on breakfast, lunch, and dinner trays were served at unpalatable and unsafe temperatures.

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure each resident had the right to a dignified existence for 2 of 2 nursing units reviewed (First and Second Floors) for dignity. Specifically, staff were observed having personal conversations at a lunch meal and not engaging or including the residents. Additionally, staff were observed discussing resident private information in a loud manner at the nursing station where others could overhear.

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure each resident was provided a clean, comfortable, and homelike environment for 1 of 1 resident (Resident #14) reviewed for homelike environment. Specifically, Resident #14 had a basin containing emesis (vomit) resting on top of the garbage can for 3 days of survey.

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident to include services that are to be furnished to maintain the resident's highest practicable physical, mental and psychosocial well-being for 1 of 2 residents (Resident #12) reviewed for communication. Specifically, Resident #12 did not have hearing aids placed for 2 days of survey and hearing aid use was not documented on the resident's comprehensive care plan (CCP).

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent decrease in range of motion for 1 of 6 residents (Resident #21) reviewed for position and mobility. Specifically, Resident #21 was observed without a palm guard (a device used between fingers and the palm to prevent injury to the palm from severe finger flexion contracture) in place as care planned.

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not maintain an infection and prevention control program designed to provide a safe, sanitary and comfortable environment and to help prevent the transmission of communicable diseases for 4 of 9 residents (Residents #20, 21, 38, and 46) observed during medication administration observations. Specifically, two licensed practical nurses (LPNs) were observed not performing hand hygiene during medication administrations.