Riverdale Post Acute

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#1) of three residents reviewed for accident hazards out of nine sample residents. Specifically, the facility failed to ensure neurological assessments were completed after Resident #1's unwitnessed fall, which resulted in a head injury.

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to serve the residents meals at appropriate temperatures.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to:-Contact the physician for clarification on what type of precaution Resident #3 needed; and,-Communicate the precautions to the staff clarify and communicate Resident #3's isolation precautions. I. Facility policy and procedure The Multidrug-Resistant Organisms policy, dated December 2024, was received from the nursing home administrator (NHA) on 4/22/26 at 6:11 p.m. It read in pertinent part, Multidrug-resistant organisms (MDROs) are bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs. Infection means the organism is present and is causing illness. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#5, and #8) of six residents reviewed out of 13 sample residents were kept free from resident-to-resident physical abuse. Specifically the facility failed to: -Protect Resident #8 from physical abuse by Resident #14; and, -Protect Resident #5 from physical abuse by Resident #9.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured and labeled in accordance with accepted professional standards. Specifically, the facility failed to:-Ensure medication and treatment carts was kept locked when not being monitored by nursing staff;-Ensure residents' medications were stored in a locked cabinet when not being monitored by the medication administration nurse; and,-Ensure residents' medications were not prepoured into medication cups, stacked on top of one another on the medication cart and left unattended in a common area of the facility.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to follow proper infection control practices during wound care for Resident #4.

Inspectors wroteBased on record review and interviews, the facility failed to ensure seven (#16, #17, #19, #8, #4, #18 and #11) of 17 residents reviewed for abuse out of 18 sample residents were kept free from abuse. Specifically, the facility failed to:-Ensure Resident #16 and Resident #17 were kept free from physical abuse toward each other on 6/7/25;-Ensure Resident #17 was kept free from physical abuse by Resident #19 on 7/29/25;-Ensure Resident #8 was kept free from physical abuse by Resident #17 on 8/14/25;-Ensure Resident #17 was kept free from physical abuse by Resident #19 on 8/31/25;-Ensure Resident #19 and Resident #17 were kept free from physical abuse toward each other on 9/17/25;-Ensure Resident #4 was kept free from physical abuse by Resident #5 on 6/18/25;-Ensure Resident #18 was kept free from physical abuse by Resident #5 on 8/10/25; [...]

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of physical abuse to the State Survey and Certification Agency in accordance with state law for two (#6 and #17) of 17 residents reviewed for abuse out of 18 sample residents. Specifically, the facility failed to ensure incidents of alleged physical abuse involving Resident #6 and Resident #17 were reported to the State Survey Agency (SSA).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#97, #37 and #47) of eight residents reviewed for accident hazards out of 36 sample residents remained as free from accidents as possible. Resident #97, who was known to be at risk for falls, was admitted on [DATE] with diagnoses of dementia, hearing impairment, unsteady and shuffling gait, and right sided weakness. The facility initiated a fall care plan which included interventions of anticipating and meeting the resident's needs, encouraging rest periods when signs of fatigue were noted, ensuring that the resident wore appropriate footwear when ambulating and keeping the resident in line of sight as needed. Resident #97 sustained falls with injury on 12/30/24 (abrasion to the right side of his head), 1/12/25 (laceration to his head) and 1/19/25 (abrasion to the back of his head). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and in three of three unit nourishment refrigerators. Specifically the facility failed to: -Ensured the nourishment room refrigerators were maintained at a safe temperature; -Ensure health shakes were labeled in the unit nourishment refrigerators; and, -Ensure the floor, walls and ice machine in the main kitchen were maintained in a clean and sanitary condition.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement contained the required components. Specifically, the facility failed to: -Ensure the arbitration agreement presented to residents contained language that provided for the selection of a venue that was convenient to both parties; and, -Provide for the selection of a neutral arbitrator agreed upon by both parties.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity by providing care in a dignified, respectful and individualized manner for one (#26) of four residents reviewed out of 36 sample residents and on one of three units. Specifically, the facility failed to: -Ensure residents who were prescribed a puree diet received the menu options as listed on the main menu or according to their preference and prescribed diet order; and, -Provide residents on the Aspen unit with non-disposable beverage cups at meals.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure four (#59, #39, #97 and #42) of nine residents out of 36 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #59 and Resident #39 from sexual abuse by Resident #62; -Protect Resident #97 and Resident #34 from physical abuse by each other; and, -Protect Resident #42 from physical abuse by Resident #58.

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan for three (#1, #75 and #249) of six residents out of 36 sample residents for services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to: -Ensure a comprehensive care plan was developed to address Resident #1's use of supplemental oxygen and a peripherally inserted central catheter (PICC); and, -Ensure a comprehensive care plan was developed to address Resident #75 and Resident #249's insomnia.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#95, #75 and #249) of five residents out of 36 sample residents were as free from unnecessary medications as possible. Specifically, the facility failed to: -Ensure consents were obtained that included the risks versus benefits for psychotropic medications for Resident #95, Resident #75 and Resident #249; and. -Ensure Resident #95 and Resident #75 had behavior monitoring in place for the use of psychotropic medications.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet orders of puree and mechanical soft as indicated on their meal tray cards.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for three (#54, #85 and #96) of four residents out of 36 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure Resident #54, Resident #85 and Resident #96 and/or their representatives understood the agreement before signing the arbitration agreement; and, -Ensure the facility staff provided evidence Resident #54, Resident #85 and Resident #96 and/or their representatives acknowledged understanding of the components of the agreement.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on three of three units. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate hand hygiene processes when cleaning resident rooms; -Ensure high touch surfaces in residents' rooms were cleaned; -Ensure housekeeping staff followed proper cleaning techniques when cleaning residents' bathrooms; and, -Ensure enhanced barrier precautions (EBP) were followed for Resident #1, who had a peripherally inserted central catheter (PICC).

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure resident rooms, bathrooms, dining room furniture and hallways received necessary maintenance repairs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to keep resident medical records in a secure and confidential manner. Specifically, the facility failed to ensure resident meal tickets were stored privately and not accessible to guests to review in order to protect the confidentiality of resident information.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#62) of nine residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to report an incident of potential sexual abuse involving Resident #62 to the State Survey Agency (SSA).

Inspectors wroteBased on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#50) of three residents reviewed for advanced directives out of 36 sample residents. Specifically, the facility failed to document Resident #50's refusal to complete a medical orders for scope of treatment (MOST) form (a legal document that allows individuals to outline their wishes for medical interventions and end-of-life care, ensuring their preferences are followed in the event of a serious illness or decline in health) upon admission to the facility or that the resident's resuscitation choices were discussed with the resident or the resident's representative.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of one resident received treatment and care in accordance with professional standards of practice out of 36 sample residents. Specifically, the facility failed to obtain a physician's order and provide routine maintenance and care for a peripherally inserted central catheter (PICC) for Resident #1.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#50) of three residents out of 36 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Specifically, the facility failed to weigh Resident #50, who was identified to have potential nutrition problems, upon admission to monitor the resident's nutritional status.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#96) of three residents reviewed out of 36 sample residents. Specifically, the facility failed to ensure Resident #96 was assessed to ensure her safety while self-administering her tube feedings.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication administration error rate was not greater than five percent (%). Specifically, the facility's medication administration error rate was 6.06%, or two errors out of 33 opportunities for error.

Inspectors wroteBased on record review and interviews, the facility failed to meet all the requirements for the provision of hospice care for one (#26) of five residents out of 36 sample residents. Specifically, the facility failed to ensure the hospice agency notes regarding Resident #26's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency.

Inspectors wroteBased on observations and interviews, the facility failed to post, in a form and manner accessible and understandable to residents, a list of names, addresses (mailing and email) and telephone numbers of all pertinent State Agencies and advocacy groups. Specifically, the facility failed to have the State Agencies contact information posted in a readable font size and placed in an area that had ease of access for the residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one of three units were free from accident hazards. Specifically, the facility failed to ensure the alarm on the door to the outside secured patio was functioning properly.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to take the appropriate measures to control a fly infestation in the kitchen and dining room.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an effective program of pest management to ensure the facility was free of pests. Specifically, the facility failed to ensure the main kitchen, dining rooms, resident rooms and hallways were free from flies on three out of three units.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure resident's had the right to a dignified existence. Specifically, the facility failed to provide a dignified living experience adequate by answering resident call lights timely in two of three units that resulted in call light response times up to two hours and 55 minutes.

Inspectors wroteBased on interviews and record review, the facility failed to ensure freedom from resident-to-resident abuse for three (#71, #43 and #10) of six residents reviewed out of 35 sample residents. Specifically the facility failed to ensure Residents #71, #43 and #10 were free from abuse by Resident #39. All four residents lived in the secure unit. Cross-reference F744, dementia care services.

Inspectors wroteBased on record review and interview, the facility failed to conduct yearly certified nurse aide (CNA) performance reviews and provide training based on the annual reviews for five (#2, #4, #5, #6 and #7) of five CNA training files reviewed. Specifically, the facility failed to provide performance evaluation reviews annually and provide 12 hours of regular in-service education on the outcome of these reviews for CNAs hired prior to July 2022.

Inspectors wroteBased on record review and interviews the facility failed to ensure three (#39, #10 and #71) of six residents reviewed for dementia care of 32 sample residents received the appropriate dementia care treatment and services to maintain their highest practical physical, mental, and psychosocial well-being. Specifically the facility failed to: -Assess, identify and implement measures to engage Residents #39, #10 and #71 activities to help prevent resident-to-resident altercations; -Update care plans following resident to resident abuse incidents for Resident #39, #10 and #71; and, -Ensure interventions were implemented to prevent Resident #39 from abusing other residents further.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that each resident received food that was palatable, attractive, and an appetizing temperature. Specifically, the facility failed to: -Ensure food was palatable and attractive when delivered to residents; -Ensure food was served at a safe and appetizing temperature; and, -Provide condiments with meals.

Inspectors wroteBased on resident interview, record review and staff interviews the facility failed to ensure one (#81) of five residents reviewed out of 35 sample residents receive proper foot care and treatment according to standards of practice. Specifically, the facility failed to ensure Resident #81 was seen by the podiatrist timely for toenail care.

Inspectors wroteBased on interviews and record review the facility failed to provide timely dental services to meet resident needs for one (#10) of three residents reviewed for dental services out of 35 sample residents. Specifically, the facility failed to assist Resident #10 schedule a consultation for an oral surgeon to have his remaining teeth removed and to get fitted for dentures after the facility received the referral.

Inspectors wroteBased on interview and observation the facility failed to ensure resident food preferences for one (#24) out of five sample residents were honored out of 35 sample residents. Specifically, the facility failed to provide Resident #24 with the preferred vegetarian diet.