The Riverside

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and failed to ensure residents received adequate supervision to prevent accidents. This was evident for two out of two residents (Resident #14 and Resident #15). Specifically, 1). On 02/21/2025, Resident #14 was in bed eating breakfast when they were served hot water that had been reheated in the microwave by Certified Nursing Assistant #11. Resident #14 spilled hot water on their right thigh and sustained second degree burns. 2). On 09/22/2025, Certified Nursing Assistant #17 transferred Resident #15 from the bed to the wheelchair without the required assistance of a second staff member as indicated in the care plan. During the transfer, Resident #15's right leg became caught between the wheelchair's leg rest and wheel. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that an alleged violation involving neglect was reported to the New York State Department of Health within the acceptable timeframe, and that the results of all investigations were reported to the State Survey Agency within five working days of the incident. This was evident for one resident (Resident #14) out of one resident reviewed for Accidents. Specifically, an alleged violation for Resident #14 was not reported within 2 hours, and the facility did not submit a follow-up investigation report within five (5) working days of the incident.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that all allegations of abuse were thoroughly investigated. This was evident for one resident (Resident #29) out of 17 residents reviewed for Abuse. Specifically, on 03/10/2026, Resident #29 alleged that the assigned Certified Nursing Assistant was rough while assisting with turning and providing perineal care and there was no evidence the allegation was thoroughly investigated.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident received treatment and services in accordance with professional standards of practice and their comprehensive person-centered care plan. This was evident for one resident (Resident #29) of 17 residents reviewed for Abuse. Specifically, Resident #29's Kardex and Certified Nursing Assistant Documentation Survey Report documented that two staff members were required to provide all care. However, on 03/20/2026 Certified Nursing Assistant #23 provided care to Resident #29 without a second staff member.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure that, to the extent practicable, the resident or resident representative participated in the development, review, and revision of the comprehensive care plan. Specifically, the care planning meeting was not held at the time-of-day Resident #55 was available to participate. This was evident in 1 out of 3 residents reviewed for Care Plans out of 39 residents. (Resident #55) The Finds include: The facility policy and procedure titled Comprehensive Care Plans, with the last revised date of 10/01/2024, documented that the Resident/Representative is encouraged to participate in development and amendment the comprehensive care plans. The Social Worker/Designee will notify the resident and the responsible party of the care plan conference date and time. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey from 11/13/2024 to 11/20/2024, the facility did not ensure that a person-centered Comprehensive Care Plan was developed and implemented to meet the resident's goals, and address the resident's medical, physical, mental, and psychosocial needs. Specifically, 1) Resident # 100 who had diagnosis of Dementia had no care plan in to address a Dementia diagnosis. 2) Resident # 186 receiving an Anti-depressant and Opioids had no care plan in place. This was evident of two of 5 residents investigated for Unnecessary Medications out of a sample of 39 residents (Resident #100 and Resident #186).

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure an ongoing activities program was provided to meet the resident's interest and support the resident's physical, mental, and psychosocial well-being. This was evident in 2 (Resident #247 and 384) of 4 residents reviewed for Activities out of 39 sampled residents. Specifically, Residents #247 and 384, who reside in the Memory Care (Dementia) unit, were not provided with activities that met the residents' preferences and cognitive abilities.

Inspectors wroteResident #392 Based on record review and interviews conducted during the Recertification and Abbreviated (NY00338415) Survey from 11/13/2024 to 11/20/2024, the facility failed to ensure that a resident was free from physical abuse. This was evident in 1 (Resident #392) of 7 residents reviewed for abuse out of 39 total sampled residents. Specifically, on 04/06/2024 at approximately 06:30 AM, a video recording device in Resident #392's room recorded Certified Nursing Assistant #12 grabbing and hitting Resident #392 on the hands and arms.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 2/14/23 to 2/22/23, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. This was observed during Kitchen observation. Specifically, (1) the Speech Language Pathologist (SLP) did not perform hand hygiene while feeding lunch to Resident #436, 2) expired pureed banana was observed in the emergency food supply, and 3) sandwiches from the tray line was not held within acceptable parameters, at or below 41 degrees Fahrenheit (F), to prevent foodborne illness.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not maintain an effective pest control program so the facility is free of pests and rodents. This was evident for 3 (Units 2, 6, and 10) of 12 residential units. Specifically, there were multiple observations of mice and insects throughout resident rooms and common areas on Units 2, 6, and 10. The finding is: The facility policy titled Pest Control last revised 09/09/2022 documented the facility will maintain an ongoing pest control program to ensure that the building is kept free of insects and rodents. Treatment of the facility for pest and insect control is performed on a weekly basis with more frequent treatment as needed. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification and Complaint survey (NY00299038) Survey from 02/14/2023 to 02/22/2023, the facility did not ensure alleged violations involving abuse were reported to the New York State Department of Health (NYSDOH) immediately, but not later than 2 hours after the allegations were made. This was evident for 1 (Resident #293) of 3 residents reviewed for Abuse. Specifically, an allegation of abuse involving Resident #293 was not reported to the NYSDOH within 2 hours of the allegation being made.

Inspectors wroteBased on record review and interviews conducted during a Recertification and Complaint (NY00308262) Survey from 02/14/2023 to 02/22/2023, the facility did not ensure a Baseline Care Plan (BCP) was developed, implemented, and provided to the resident and resident representative (RR). This was evident for 2 (Resident #612 and #761) of 40 sampled residents. Specifically, 1) the RR of Resident #612 was not provided with a copy of the BCP upon completion, and 2) the BCP for Resident #761 did not include the resident's anticoagulant therapy.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint (NY00306631) Survey from 2/14/23 to 2/22/23, the facility did not ensure a resident's Comprehensive Care Plan (CCP) was reviewed and revised to reflect a change in the resident's status. This was evident for 2 (Resident # 18 and #184) of 40 sampled residents. Specifically, the CCP related to abuse prevention was not reviewed and revised for Resident #18 and #184 following their involvement in a resident-to-resident altercation.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 2/14/2023 to 2/22/2023, the facility did not ensure residents with limited range of motion (ROM) received appropriate treatment and services to prevent further decrease in ROM. This was evident in 2 (Resident #55 and #334) of 3 residents reviewed for Positioning/Mobility. Specifically, 1) Resident #55 was observed without a right flex hand splint (RFHS) and left hand roll (LHR) in place per Medical Doctor's Order (MDO), and 2) Resident #334 was observed with inconsistent application of bilateral hand carrots (BHC) and bilateral elbow splints (BES). [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 2/14/2022 to 2/22/2022, the facility did not ensure a resident with respiratory care was provided such care consistent with professional standards of practice. This was evident for 1 (Resident #55) of 2 residents reviewed for respiratory care out of 40 sampled residents. Specifically, Resident #55 was observed receiving oxygen via Nasal Cannula (NC) without a Medical Doctor's Order (MDO).

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 2/14/23 to 2/22/23, the facility did not ensure a resident was seen by a physician every 60 days. This was evident for 1 (Resident #282) of 40 total sampled residents. Specifically, Resident #282 did not have a Medical Doctor (MD) visit within 60 days of their last MD visit.

Inspectors wroteBased on record review and interviews conducted during the recertification and complaint (NY00308262) survey from 2/14/23 to 2/22/23, the facility did not ensure a resident was provided pharmaceutical services to meet their needs. This was evident for 1 (Resident #761) of 40 total sampled residents. Specifically, the pharmacy did not dispense an anticoagulant (AC), Xarelto, to the facility in accordance with Medical Doctor Order (MDO) for Resident #761.

Inspectors wroteBased on record review and interviews conducted during the recertification and complaint survey (NY00308262) from 2/14/23 to 2/22/23, the facility did not ensure a resident was free of significant medication errors. This was evident for 1 (Resident #761) of 40 total sampled residents. Specifically, Resident #761 did not receive their anticoagulant (AC), Xarelto, in accordance with Medical Doctor Order (MDO).

Inspectors wroteBased on observation and staff interviews conducted during the Recertification survey, the facility did not ensure that all equipment was being maintained in a clean, sanitary manner. Specifically, the meat slicing machine was observed to have debris imbedded after being cleaned by staff. This was observed during the Kitchen Observation task. The finding is: The policy titled Cleaning Instructions- Slicers dated 6/13/19 documented the slicer would be cleaned and sanitized after each use. The policy also documented clean all removable parts in the pot and pan sink, sanitize all removable parts in a chemical sanitizer, immerse for the appropriate amount of time to sanitize and carefully clean the remaining parts with hot detergent water, rinse and dry. [...]