How many inspection deficiencies does NEW RIVERDALE REHAB AND NURSING have?

NEW RIVERDALE REHAB AND NURSING has 22 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at NEW RIVERDALE REHAB AND NURSING?

NEW RIVERDALE REHAB AND NURSING has a three-star staffing rating from CMS with 0.44 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is NEW RIVERDALE REHAB AND NURSING located?

NEW RIVERDALE REHAB AND NURSING is located in BRONX, NY. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does NEW RIVERDALE REHAB AND NURSING have?

NEW RIVERDALE REHAB AND NURSING has 146 certified beds.

Who owns NEW RIVERDALE REHAB AND NURSING?

NEW RIVERDALE REHAB AND NURSING is a for profit - limited liability company facility and is part of the CITADEL CARE CENTERS chain.

How does NEW RIVERDALE REHAB AND NURSING compare to other nursing homes?

NEW RIVERDALE REHAB AND NURSING has a 2-star overall rating, which is below average compared to other nursing homes in NY. Families should carefully review inspection findings and consider alternatives.

NEW RIVERDALE REHAB AND NURSING

Name: NEW RIVERDALE REHAB AND NURSING
Address: 641 WEST 230TH ST, BRONX, NY, 10463, US
Telephone: (718) 796-4800
Rating: 2.0

641 WEST 230TH ST, BRONX, NY 10463 · (718) 796-4800

For profit - Limited Liability company 146 Beds CITADEL CARE CENTERS Data: November 2025

Trust Grade

23/100

#425 of 594 in NY

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Last Inspection: March 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

New Riverdale Rehab and Nursing has received a Trust Grade of F, indicating significant concerns about their care and operations. They rank #425 out of 594 facilities in New York, placing them in the bottom half of nursing homes in the state, and #39 out of 43 in Bronx County, meaning only a few options are worse. The facility's performance has worsened in recent years, with the number of issues rising from 5 in 2023 to 11 in 2025. Although staffing is rated average with a turnover rate of 30%, which is better than the state average, the facility has incurred fines totaling $93,279, which is higher than 93% of New York facilities, suggesting ongoing compliance issues. Specific incidents include a resident being punched by another due to insufficient supervision, and reports of inadequate living conditions, including unclean rooms and broken furniture, highlighting both serious and concerning operational weaknesses.

Trust Score: F
In New York: #425/594
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 30% annual turnover. Excellent stability, 18 points below New York's 48% average. Staff who stay learn residents' needs.
Penalties: $93,279 in fines. Lower than most New York facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for New York. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 22 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★☆

4.0

Care Quality

★★☆☆☆

2.0

Inspection Score

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Stable

2023: 5 issues

2025: 11 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Low Staff Turnover (30%) · Staff stability means consistent care
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover is low (30%)
18 points below New York average of 48%

Facility shows strength in quality measures, staff retention, fire safety.

The Bad

2-Star Overall Rating

Below New York average (3.1)

Below average - review inspection findings carefully

Federal Fines: $93,279

Well above median ($33,413)

Moderate penalties - review what triggered them

Chain: CITADEL CARE CENTERS

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 22 deficiencies on record

1 actual harm

Mar 2025 11 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Resident #117's injury required seven (7) sutures and necessitated two (2) trips to the emergency room. This resulted in actual harm to Resident #117 that was not Immediate Jeopardy. The findings are: The facility's policy titled Clinical Protocol for Abuse and Neglect with a last reviewed date of 01/2025 stated that abuse may be defined as the willful infliction of injury of punishment with resulting physical harm. Willful, as used in this definition of abuse, means the individual must have acted deliberately. An Accident Investigation Report dated 02/08/2025 documented on 02/08/2025 at approximately 12:30 PM, Resident #117 stated another resident punched them in the forehead while they were using the toilet. Resident #242 stated they punched Resident #117 because they were taking too long, and they wanted to take a shower. The Supervisor Investigative Summary report documented Resident #242 had history of paranoid schizophrenia and had been known to experience periods of severe aggression during which they threatened and physically attacked staff and residents. Resident #242 was erratic and displayed flat affect with no remorse for the occurrence. To prevent reoccurrence, Resident #242 was escorted by the police to the precinct. The Facility Investigation dated 02/08/2025 completed by the Director of Nursing stated on 02/08/2025 at approximately 12:30 PM, staff responded to Resident #117 who was holding their forehead stating that Resident #242 punched them several times in the forehead. Resident #117 was noted with bleeding and skin opening to the forehead. The facility investigation documented on 02/08/2025 at 12:15 PM, Resident #242 was observed exiting their room with washcloth and towels in their hand heading towards the bathroom. At 12:25 PM Resident #117 was observed entering the same bathroom and then exited at 12:30 PM holding their forehead. 911 was activated. Two police officers responded and escorted Resident #242 out of the facility in handcuffs. The Social Worker followed up with the precinct and was informed that Resident #242 had been released to a shelter on 02/09/2025 . Resident #117 was transferred to the emergency room and returned the same day with diagnosis of laceration repair with seven (7) intact sutures. The facility investigation did not indicate which part of Resident #117 had laceration. The facility concluded it was an isolated incident and there was no cause to believe any alleged resident abuse, exploitation, or neglect occurred. The investigation documented the investigation had not identified deviation from residents' care plan. The facility investigation further documented it was an isolated incident and systemic actions were not identified. 1.) Resident #242 was admitted to the facility with diagnoses of paranoid schizophrenia (a mental health condition characterized by persistent, irrational, and unfounded beliefs that others are conspiring or intending to harm or deceive the individual), Diabetes Mellitus (a disorder characterized by high blood sugar level), and peripheral vascular disease (a condition where blood vessels outside the heart and brain become narrowed or blocked, reducing blood flow to the extremities). The Minimum Data Set (a resident assessment tool) dated 11/24/2024 documented Resident #242 had intact cognition, was ambulatory, and was independent in activities of daily living. A care plan for abuse/victim was initiated for Resident #242 on 06/14/2022. The care plan documented Resident #242 was at risk to abuse others related to poor impulse control, as well as verbally and physically abusive behavior. There were no goals or interventions documented in the care plan. A care plan note dated 05/05/2023 documented Resident #242 hit another resident on the head with a chair. A care plan note dated 04/04/2024 documented Resident #242 slapped their roommate's face. There was no documented evidence that the care plan for abuse/victim has been reviewed for each episode of resident altercations or that interventions were in place to prevent resident to resident abuse. A care plan for behavior as evidenced by actual peer-to-peer physical altercation and aggressive/destructive behavior was initiated for Resident #242 on 07/27/2022. The facility interventions included to notify the physician of changes in behavior, social service evaluation and follow-up, and staff to observe and redirect when resident wanders away from their room. The behavior care plan notes documented as per nursing progress note dated 07/31/2022, Resident #242 exhibited threatening and verbally aggressive behavior toward staff. A care plan note dated 05/05/2023 documented Resident #242 hit another resident on the head with a chair. A care plan note dated 01/18/2024 documented on 01/15/2024, Resident #242 used offensive language towards their roommate and was moving towards the roommate in a threatening manner. A care plan note dated 02/16/2024 documented Resident #242 hit another resident in the face. A care plan note dated 04/04/2024 documented Resident #242 slapped their roommate in the face. There was no documented evidence that the facility evaluated the effectiveness of the care plan interventions or updated the interventions after each episode of resident altercations, and there were no interventions to assure the safety of other residents. A nurse's progress note dated 02/08/2025 at 7:33 PM documented at approximately 12:30 PM, Resident #242 punched Resident #117 in the head. Resident #242 had been known to exhibit periods of severe aggression during which they physically attacked and threatened staff and residents. Given the escalating nature of the situation, 911 was called. Resident #242 was transported by the police at approximately 1:20 PM. 2.) Resident #117 was admitted to the facility with diagnoses of opioid dependence (a physical and psychological need for pain relieving medications), Hypothyroidism (a condition that happens when your thyroid gland doesn't make or release enough hormone) and chronic viral Hepatitis C (an infection that affects the liver). The Minimum Data Set, dated [DATE] documented Resident #117 was moderately cognitively impaired and required partial/moderate assistance with toileting, and shower/bathing. Resident #117 was able to walk 10 feet with partial/moderate assistance and used a manual wheelchair for mobility. A care plan for potential for abuse was initiated for Resident #117 on 09/23/2024. The care plan documented Resident #117 had potential to be abused by peers secondary to congregate living. The care plan goal was for Resident #117 to be free from abuse by others. The facility interventions included to assist resident to develop familiar and trusting relationship and offer positive behavior. A nurse's progress note dated 02/08/2025 at 7:09 PM documented at 12:30 PM, staff responded to Resident #117 who stated they were punched by another resident. Resident #117 was noted with 1.5 x 0.5 x 1.0 centimeter laceration on the forehead. Resident #117 stated Resident #242 told them to get out while they were using the toilet. Resident #117 stated they were taking too long and then Resident #242 punched them several times in the head. Resident #117 was transferred to the emergency room for further evaluation. A nurse's progress note dated 02/08/2025 at 10:31 PM documented Resident #117 returned from the hospital at 7:39 PM. The notes documented as per emergency room after visit summary, Resident #117 had a computed tomography scan (a type of imaging that uses X-ray techniques to create detailed images of the body) of the cervical spine, head, and face with negative findings. Laceration repair done (the note did not indicate which body part) with seven (7) intact sutures. Resident's left eye was swollen with minimal bleeding noted. A nurse's progress note date dated 02/10/2025 at 10:49 PM by Registered Nurse #3 documented Resident #117 had profuse bleeding in his left inner upper eyelid, dressing was saturated with blood oozing from the skin opening. Pressure dressing was not enough to control the bleeding, 911 was called and resident was transferred to the emergency room. Resident returned to the facility with no new orders. A physician's progress note dated 02/11/2025 at 4:01 PM documented Resident #117 was seen and examined following an emergency room visit for traumatic facial injury sustained during a resident-to-resident altercation. Physical examination revealed redness of the right conjunctiva (outer membrane of the eyeball and inner eyelid), facial bruises, bilateral eyelid swelling, with the left eye swollen completely shut. Resident #117 had a cut on the forehead with stitches, right eye redness, and left eye swollen shut due to eyelid edema. The progress note documented bleeding was controlled, to increase staff surveillance for safety precautions, eye bandaging to prevent scratching, eyedrops for irritated eyes to both eyes, to continue eye care and wound monitoring, and reassess for swelling and signs of infection. On 03/18/2025 at 12:44 PM, The Social Service Director was interviewed and stated Resident #242 was known to have a short fuse and has had a history of aggressive behavior. On 03/19/2025 at 9:44 AM, the Director of Nursing was interviewed and stated they investigated the incident that occurred on 02/08/2025 involving Residents #242 and #117. They stated Resident #242 had no insight and their action was psychiatrically motivated. They stated Resident #117 likes to stay in the hallway in front of their room and chose to use the bathroom at the same time that Resident #242 wanted to shower. The Director of Nursing stated they concluded abuse had not occurred because Resident #242 had no actual intent to harm Resident #117. On 03/19/2025 at 4:22 PM, the Administrator was interviewed and stated the incident on 02/08/2025 involving Residents #242 and #117 could have not been predicted or prevented. 10 NYCRR 415(b)(1)(i)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are: The facility policy titled Activities of Daily Living, Shower with the last revised date of 01/2025 documented that it is the facility's policy to shower residents, cleanse and refresh them, observe their skin, and increase circulation. Staff are to check the assigned shower schedule for their shift. Resident #5 was admitted to the facility with diagnoses that include Chronic Obstructive Pulmonary Diseases and Heart Failure. The annual Minimum Data Set assessment dated [DATE] documented Resident #5 had intact cognition and that it was very important for Resident #5 to choose between a tub bath, shower, or sponge bath. On 03/13/2025 at 11:29 AM, Resident #5 was observed resting in their room. Resident #5 was interviewed and stated that the last time they got a shower was almost two months ago. The resident stated they were washed in bed although sometimes they would like to get a shower. A care plan for occupational therapy, activities of daily living, self-care perfromance deficit was initiated for Resident #5 on 02/03/2025. The facility interventions included one person physical assist for bathing, bathing types were bed bath, shower, and sponge bath. The Resident Shower Schedule documented that Resident 5 had showers scheduled on Tuesdays and Fridays during the 3:00 PM to 11:00 PM shift. The Resident Certified Nursing Assistant Documentation History Detail Report dated 01/03/2025 to 03/14/2025 documented Resident #5 received bed baths. Review of Resident #5's medical record did not reveal documentation that the resident refused showers. On 03/17/2025 at 3:44 PM, Certified Nursing Assistant #1 was interviewed and stated that Resident # 5 was scheduled for showers in the afternoon. They stated Resident #5 gets a bed bath because they refuse showers. On 03/17/2025 at 3:57 PM, Licensed Practical Nurse #1 was interviewed and stated that Resident #5 gets a bed bath and does not get a shower. They stated they had not receive any report from the Certified Nursing Assistant that Resident #5 refused showers. On 03/17/2025 at 4:05 PM, Registered Nurse #1, who was the nursing supervisor, was interviewed and stated that Resident #5 has shower scheduled on Tuesdays and Fridays during the 3:00 PM to 11:00 PM shift. They stated Resident #5 is given bed baths and was never taken to the bathroom for a shower. Registered Nurse #1 stated there was no documentation that the bed bath is the resident's preference, or that Resident #5 refused showers, or that the resident preferred a bed bath to a shower. On 03/19/2025 at 1:54 PM, the Director of Nursing was interviewed and stated that it is the facility's policy to shower the residents twice a week and as needed. They stated that, it was documented that Resident #5 received bed baths and there was no documentation that Resident #5 refused showers. The Director of Nursing stated the nurse on the unit is responsible for ensuring that care is provided to the residents as ordered. 10 NYCRR 415.5(b) (1-3)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are: The facility policy titled Care Planning- Interdisciplinary Team with a last revised date of 01/2025 documented that the interdisciplinary team is responsible for the development of resident care plans. Resident #36 was admitted to the facility with diagnoses that included Arthritis and Hypertension. The admission Minimum Data Set assessment dated [DATE] documented Resident #36's cognition was intact. On 03/12/2025 at 2:14 PM, Resident #36 was interviewed and stated that 2 weeks ago, a Certified Nursing Assistant called them handicapped and reported the incident to the Assistant Director of Nursing. The facility incident report dated 01/25/2025 documented that at approximately 12:00 PM, Resident #36 reported that the Certified Nursing Assistant called them handicapped and crippled A review of Resident #36's comprehensive care plans had no documented evidence that a care plan for at risk for abuse or victimization was developed for Resident #36. On 03/19/2025 at 1:39 PM, the Director of Nursing was interviewed and stated Resident #36 was discharged to their home in 2024 and was readmitted to the facility in January of this year. They stated there was no abuse care plan initiated for Resident #36 when they were again admitted to the facility. On 03/19/2025 at 9:18 AM, the Administrator was interviewed and stated they should have opened a new medical chart when Resident #36 was again admitted to the facility in January 2025. The alleged verbal abuse allegation should have been included in the abuse care plan. 10 NYCRR 415.11(c)(1)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 The findings are: The facility policy titled Laboratory and Diagnostic Test Results with a revised date of 01/2025 documented that the Physician will identify, and order diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider or other testing source will report test results to the facility. Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the Director of Nursing and/or the Medical Director. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation. Resident #39 had diagnoses of Non-Alzheimer's Dementia and Schizoaffective Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #39 had moderately impaired cognition and had received anticonvulsive and antipsychotic medications since admission/entry or reentry into the facility. A physician order which was initiated on 01/25/2023 and renewed on 02/25/2025 documented a medication order for Depakote Sprinkles 125 milligram capsules, delayed release, 5 capsules (625 milligrams) to be administered by oral route 3 times a day with food. A Medication Administration Record dated March 2025 documented that Resident #39 was administered 625 milligrams of Depakote Sprinkles by oral route 3 times a day. A care plan for psychotropic use was initiated for Resident #39 which was last reviewed on 03/07/2025. The facility interventions include to monitor laboratory results for drug levels. A Pharmacy Consultant Medication Regimen Review progress note dated 02/11/2025 documented Resident #39 was currently receiving Depakote, unable to locate a recent serum level in the chart, recommended 2 weeks after start then every 6 months thereafter. The note documented to please consider ordering. A Medication Regimen Review Response progress note dated 02/12/2025 documented the Nurse Practitioner's response to the Consultant Pharmacist's recommendation for Resident #39 as follows -Agree Will do. A Physician Laboratory Order dated 02/12/2025, documented Depakene - Serum Valproate one time 02/13/2025. There was no documented evidence that the serum level for Depakote was drawn. There was no documented evidence that the licensed nurses, physician, or the nurse practitioner followed up if the serum level has been completed. On 03/19/2025 at 9:23 AM, the Nurse Practitioner was interviewed and stated that Depakote level was ordered for Resident #39 on 02/12/2025 as recommended by the pharmacy consultant. The Nurse Practitioner stated they wait for the Registered Nurse to inform them of the laboratory test results. They stated they were not notified of the results or the reason why was the serum level not obtained. On 03/19/2025 at 12:23 PM, the Medical Director was interviewed and stated the Nurse Practitioner should have followed up timely when they had not received the laboratory results. On 03/19/2025 at 10:58 AM, the Director of Nursing was interviewed and stated that the expectation was that the attending physician or rhe nurse practitioner will follow up on the laboratory results. 10 NYCRR 415.11(c)(3)(i)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are: The facility policy titled Weight Policy with a revision date of 03/2025 documented the purpose of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the idea weight of the resident. Resident #122 had diagnoses of Hypertension, Unspecified Protein Calorie Malnutrition, and Right Below Knee Amputation and Right Foot Burn. The Minimum Data Set assessment dated [DATE] documented Resident #122 had intact cognition and required minimal assistance and supervision with activities of daily living. A review of the Comprehensive Care Plan on Nutritional Status dated 09/22/2024 documented Resident #122 was at risk for nutrition related problem secondary to diagnosis of thiamine and vitamin deficiency. The goal set was nutrition - related laboratories results will be at baseline for medical condition, will be free from chewing and swallowing difficulties, will increase 1-2 pounds weight gradually and Per Orem intake will be sufficient to support nutrition and hydration needs. The interventions were listed as follows: consult with physician as needed, consult with dietician as needed , daily calorie needs based on ideal Body weight of 148 pounds or 67 kilograms. The total calorie needs was calculated at 1675-2010 total calorie needs, 67 grams of protein and 1657 to 2101 milliliter of fluids, to monitor food consumption during mealtimes, and monitor weekly weight. A review of the resident's weight from 11/29/2024 to 02/28/2025 showed an undesirable weight loss of 12% in the last 3 months. 11/29/2024 - 133 pounds 12/13/2024 - 125.2 pounds 12/20/2024 - 134 pounds 12/27/2024 - 133.9 pounds 01/03/2025 - 116.6 pounds 01/10/2025 - 116 pounds 01/24/2025 - 116.1 pounds 02/28/2025 - 117 pounds A review of Resident #122's care plan and dietary notes revealed no intervention to address the significant weight loss of 17.3 pounds in January 2025. The 03/11/2025 3:51 PM dietary progress note documented Resident #122 had significant and undesirable weight loss of 16 pounds, 12% in 3 months; 20.4 pound weight loss, 14.8% in 5 months. Weight is pending for March. The dietary note documented, weight loss was discussed with the resident who acknowledged he has good appetite and that they were losing weight prior to admission due to their illness. The plan was to monitor intake and weekly weights. During an interview with the Registered Dietician on 03/14/2025 at 12:06 PM, they stated they have not seen Resident #122's January and February weight record and was informed of the weight loss in March. They stated they only come to the facility twice a week and cannot do everything. During an interview with Nurse Practitioner #1 on 03/14/2025 at 12:51 PM, they stated they were not aware of Resident #122's weight loss until March. They stated they do not remember anybody discussing the resident's weight loss with them. They stated that the recommendations to manage weight loss should come from the dietitian. During an interview with the Assistant Director of Nursing on 03/14/2025 at 1:14 PM, they stated changes in a resident's diet and weight loss are discussed during the morning meeting and is communicated to the dietary department. They stated weight records are on the resident's notes and can be reviewed by the dietitian. 10 NYCRR 415.12 (i)(1)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 The findings are: The facility policy titled Laboratory and Diagnostic Test Results with a revised date of 01/2025 documented that the Physician will identify and order diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider or other testing source will report test results to the facility. Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the Director of Nursing and/or the Medical Director. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation. The facility policy titled Physician Services with a reviewed date of 01/2025 documented that the physician will address laboratory and other diagnostic test results in a timely manner based on the resident's condition and the clinical significance of the results. The physician will periodically review all medications prescribed for their patients and will monitor both for continuing indications and for possible adverse drug reactions. The medication review should take into account observations and concerns offered by pharmacy consultants and others regarding beneficial and possible adverse impacts of medications on the resident. The attending physician will perform accurate, timely and relevant assessments as needed. The physician will respond to notification of and will assess and manage acute and significant changes in resident condition. Resident #39 had diagnoses of Non-Alzheimer's Dementia and Schizoaffective Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #39 had moderately impaired cognition and had received anticonvulsive and antipsychotic medications since admission/entry or reentry into the facility. A physician order which was initiated on 01/25/2023 and renewed on 02/25/2025 documented a medication order for Depakote Sprinkles 125 milligram capsules, delayed release, 5 capsules (625 milligrams) to be administered by oral route 3 times a day with food. A Medication Administration Record dated March 2025 documented that Resident #39 was administered 625 milligrams of Depakote Sprinkles by oral route 3 times a day. A care plan for psychotropic use was initiated for Resident #39 which was last reviewed on 03/07/2025. The facility interventions include to monitor laboratory results for drug levels. A Pharmacy Consultant Medication Regimen Review progress note dated 02/11/2025 documented Resident #39 was currently receiving Depakote, unable to locate a recent serum level in the chart, recommended 2 weeks after start then every 6 months thereafter. The note documented to please consider ordering. A Medication Regimen Review Response progress note dated 02/12/2025 documented the Nurse Practitioner's response to the Consultant Pharmacist's recommendation for Resident #39 as follows -Agree Will do. A Physician Laboratory Order dated 02/12/2025, documented Depakene - Serum Valproate one time 02/13/2025. There was no documented evidence that the serum level for Depakote was drawn. There was no documented evidence that the physician or the nurse practitioner followed up if the serum level has been completed. On 03/19/2025 at 9:23 AM, the Nurse Practitioner was interviewed and stated that Depakote level was ordered for Resident #39 on 02/12/2025 as recommended by the pharmacy consultant. The Nurse Practitioner stated they wait for the Registered Nurse to inform them of the laboratory test results. They stated they were not notified of the results or the reason why was the serum level not obtained. On 03/19/2025 at 12:23 PM, the Medical Director was interviewed and stated the Nurse Practitioner should have followed up timely when they had not received the laboratory results. 10 NYCRR 415.15 (b)(2)(iii)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are: The facility policy titled Drug Regimen Review with a revised date of 03/2025 documented that in accordance with Code of Federal Regulations 42 CFR 483.45, the Consultant Pharmacist shall review the medical record of each resident and perform a Drug Regimen Review at least once each calendar month. The Consultant Pharmacist shall identify, document, and report possible medication irregularities for review and action by the attending Physician, where appropriate. The attending Physician or licensed designee shall respond to the Drug Regimen Review within 30 days or more promptly whenever possible and act upon the Drug Regimen Review Findings/recommendation in a timely manner of 30 days or less by documenting on the drug regimen review form whether they agree or disagree with the recommendation. The facility policy titled Laboratory and Diagnostic Test Results with a revised date of 01/2025 documented that the physician will identify and order diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider or other testing source will report test results to the facility. Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the Director of Nursing and/or the Medical Director. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation. Resident #39 had diagnoses of Non-Alzheimer's Dementia and Schizoaffective Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #39 had moderately impaired cognition and had received anticonvulsive and antipsychotic medications since admission/entry or reentry into the facility. A physician order which was initiated on 01/25/2023 and renewed on 02/25/2025 documented a medication order for Depakote Sprinkles 125 milligram capsules, delayed release, 5 capsules (625 milligrams) to be administered by oral route 3 times a day with food. A care plan for psychotropic use was initiated for Resident #39 which was last reviewed on 03/07/2025. The facility interventions include to monitor laboratory results for drug levels. A Pharmacy Consultant Medication Regimen Review progress note dated 02/11/2025 documented Resident #39 was currently receiving Depakote, unable to locate a recent serum level in the chart, recommended 2 weeks after start then every 6 months thereafter. The note documented to please consider ordering. A Medication Regimen Review Response progress note dated 02/12/2025 documented the Nurse Practitioner's response to the Consultant Pharmacist's recommendation for Resident #39 as follows -Agree Will do. A Physician Laboratory Order dated 02/12/2025, documented Depakene - Serum Valproate one time 02/13/2025. There was no documented evidence that the serum level for Depakote was drawn. On 03/19/2025 at 9:23 AM, the Nurse Practitioner was interviewed and stated that Depakote level was ordered for Resident #39 on 02/12/2025 as recommended by the pharmacy consultant. The Nurse Practitioner stated they wait for the Registered Nurse to inform them of the laboratory test results. They stated they were not notified of the results or the reason why was the serum level not obtained. On 03/19/25 at 10:58 AM, the Director of Nursing was interviewed and stated if the sample was not collected, the laboratory should communicate with the nurse. The Director of Nursing stated a follow up should have been done for laboraory requests that were not completed. 10 NYCRR 415.18(c)(2)

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings include but are not limited to: The facility's policy titled Maintenance Service with a revised date of 01/07/2025 documented maintenance service shall be provided to all areas of the building, grounds, and equipment in a safe and operable manner at all times. During multiple observations from 03/12/2025 at 9:23 AM to 03/14/2025 at 12:35 PM, the following were observed in Unit 3: room [ROOM NUMBER]E 308A had urine-stained mattress, and a closet with holes and missing a lock. room [ROOM NUMBER]E 308B was noted with strong urine odor, missing nightstand, and sticky floor with brown colored stains. room [ROOM NUMBER]E 310B had damaged wall surface by the head of the bed board, blue tape was observed on the television remote control. room [ROOM NUMBER]E 312B was without a television. room [ROOM NUMBER]E 312C had dusty and broken television which was missing a power cord, and stained privacy curtain. Multiple rooms in Unit 3 had walls with scratches/scruff marks, cracked and chipped paints and floors were noted with sticky stained substance. Wooden closets were observed with scuff marks and scratches and were missing locks. The Unit 3 Maintenance Log from 01/01/2025 to 03/14/2025 did not contain repair requests for the above observations. The Environmental Rounding Checklist dated 03/04/2025 documented room [ROOM NUMBER] was noted with a broken dresser and room [ROOM NUMBER] had walls with splatter. On 03/18/2025 at 12:31 PM, the Facilities Director stated they conduct weekly environmental rounds, and repairs are completed when there are issues found. The Facilities Director stated they replaced the broken dresser in room [ROOM NUMBER] and completed the repairs found during environmental rounds conducted on 03/04/2025. The Facilities Director stated the housekeeping staff are responsible for emptying garbage bins and basic cleaning of resident rooms and bathrooms. They stated privacy curtains are checked daily and must be replaced if stained. On 03/19/2025 at 2:21 PM, the Administrator was interviewed and stated the team will work on a plan to correct the environmental problems to ensure residents are provided with clean, homelike environment 10 NYCRR 415.5(h)(2)

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #36 had diagnoses of Arthritis and Hypertension. The Minimum Data Set assessment dated [DATE] documented Resident # 36 had intact cognition and required substantial assistance with personal hygiene. On 03/12/2025 at 2:14 PM, Resident #36 was interviewed and stated that two weeks ago, a Certified Nursing Assistant called them handicapped and reported the incident to the Assistant Director of Nursing. The facility incident report dated 02/25/2025 documented that Resident #36 reported that the Certified Nursing Assistant who was assigned to them called them handicapped and crippled . The facility investigation concluded there was no evidence to believe an alleged abuse, neglect, or mistreatment occurred. On 03/19/2025 at 1:23 PM, the Director of Nursing was interviewed and stated Resident #36 told them that a Certified Nursing Assistant called them handicapped. The Director stated they initiated an investigation and Certified Nursing Assistant 7 denied the allegation. The Director of Nursing stated the allegation was not reported to the New York State Department of Health because they concluded that the incident was a customer service issue and not verbal abuse. On 03/19/2025 at 9:18 AM, the Administrator was interviewed and stated that the Director of Nursing is responsible for reporting abuse cases to the Department of Health. The Administrator stated the Director of Nursing did not inform them of Resident #36's allegation of verbal abuse against the aide. The Administrator stated the allegation was verbal abuse and should have been reported to the New York State Department of Health. 4. Resident #242 was admitted to the facility with diagnoses of paranoid schizophrenia (a mental health condition characterized by persistent, irrational, and unfounded beliefs that others are conspiring or intending to harm or deceive the individual), Diabetes Mellitus (a disorder characterized by high blood sugar level), and peripheral vascular disease (a condition where blood vessels outside the heart and brain become narrowed or blocked, reducing blood flow to the extremities). The Minimum Data Set (a resident assessment tool) dated 11/24/2024 documented Resident #242 had intact cognition, was ambulatory, and was independent in activities of daily living. An Accident Investigation Report dated 02/08/2025 documented on 02/08/2025 at approximately 12:30 PM, Resident #117 stated another resident punched them in the forehead while they were using the toilet. Resident #242 stated they punched Resident #117 because they were taking too long, and they wanted to take a shower. The Supervisor Investigative Summary report documented Resident #242 had history of paranoid schizophrenia and had been known to experience periods of severe aggression during which they threatened and physically attacked staff and residents. Resident #242 was erratic and displayed flat affect with no remorse for the occurrence. The incident was reported to the New York State Department of Health on 02/09/2025 at 1:51 AM. On 03/19/2025 at 9:44 AM, the Director of Nursing was interviewed and stated the team felt abuse had not occurred because they felt that Resident #242 had no insight and did not intend to injure Resident #117, therefore, they felt no urgency to report the incident within the 2 hour timeframe to the New York State Department of Health. 10 NYCRR 415.4(b)(2) Based 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. Resident #93 was unable to explain how they sustained the swelling and discoloration. This injury of unknown source was not reported to the New York State Department of Health. 3.) On 02/25/2025 at approximately 12:30 PM, Resident #36 reported that a Certified Nursing Assistant called them handicapped and crippled. This allegation of verbal abuse was not reported to the facility administrator and to the New York State Department of Health. 4.) On 02/08/2025 at approximately 12:30 PM, Resident #242 punched Resident #117 in the head. This incident was reported to the New York State Department of Health on 02/09/2025 at 1:51 AM. The findings are: The facility's policy titled Abuse and Neglect with a revised date of 01/2025 documented the facility will ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than two hours after the allegation is made, if the event cause the allegation involve abuse, or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse or result in serious bodily injury to the administrator of the facility and to other officials including to the State Survey Agency. 1. Resident #25 had diagnoses of Diabetes Mellitus, Major Depressive Disorder, and Cerebrovascular Disease. The Minimum Data Set assessment dated [DATE] documented Resident #25 had intact cognition. On 03/12/2025 at 10:55 AM, Resident #25 was interviewed and stated they were assaulted by a staff in the morning of 2/14/2025 and was reported to the charge nurse. The facility Incident Report dated 02/14/2025 documented Resident #25 reported their assigned Certified Nursing Assistant was too rough and tried to woke resident up from their sleep on 02/14/2025 around 5:00 AM. The facility investigation concluded there was no reasonable cause to believe that alleged abuse, neglect, or mistreatment occurred. There was no documented evidence Resident #25's allegation that the staff was rough during care was reported to the New York State Department of Health. On 3/18/2025 at 11:30 AM, the Assistant Director of Nursing was interviewed and stated on 02/14/2025 at around 3:00 PM, Resident #25 reported that the aide assigned to them was too rough during care earlier that morning. The Assistant Director of Nursing stated they immediately initiated the investigation and was able to conclude that the allegation was not an abuse but a staff performance and customer service issue. On 03/19/2025 at 12:33 PM, the Director of Nursing was interviewed and stated that the report made by Resident #25 that a staff was rough during care was not an allegation of abuse therefore, they did not report the alleged incident to the New York State Department of Health. 2. Resident #93 had diagnoses of Dementia, Mood Disorder, and Paranoid Schizophrenia. The Minimum Data Set assessment dated [DATE] documented Resident #93 had short and long term memory problem and moderately impaired cognitively skills for daily decision making. A medical progress note dated 02/24/2025 documented Resident #93 had right eyelid swelling and dark discoloration. Resident #93 had dementia and history was not obtainable. The medical note documented Resident #93 was assessed with traumatic right eyelid injury. There was no documented evidence that the injury was reported to the New York State Department of Health. On 03/19/2025 at 12:33 PM, the Director of Nursing stated Resident #93 has a behavior of rubbing their face on the wall which is their baseline. It was not reported to the New York State Department of Health since it was not considered an unknown injury.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are: The facility policy titled Care Plan-Comprehensive with a last revised date of 01/2025 documented that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team reviews and updates the care plan when the desired outcome is not met. Resident #40 had diagnoses that included Anxiety Disorder and Schizophrenia. The quarterly Minimum Data Set assessment dated [DATE] documented Resident # 40 had moderately impaired cognition. A Comprehensive Care Plan for Smoking - danger to self and other was initiated for Resident #40 on 05/09/2023. The care plan documented that Resident #40 was a known smoker. The facility interventions included allowing the resident to smoke in a designated smoking area with supervision as needed and checking clothing regularly for signs of unsafe smoking. A care plan note dated 05/24/2023 documented Resident #40 was observed hiding a cigarette in their pocket, a lighter was also found in their pocket. A care plan notes dated 10/24/2023 and 12/26/2023 documented Resident #40 was observed smoking in their room. There was no documented evidence that the facility updated the care plan interventions after the incidents on 05/24/2023, 10/24/2023, and 12/26/2023. A nuse's progress note dated 09/12/2024 at 1:54 AM documented that at approximately 12:30 AM, Resident #40 was seen going to the first-floor bathroom. The staff checked Resident #40's pockets and found a lit cigarette and a lighter. Resident #40 was redirected back to their room and reminded of the facility's smoking policy. A review of Resident #40's smoking care plan had no documented evidence that the care plan was revised with new interventions after the incident on 09/12/2024. On 03/18/2025 at 12:30 PM, Registered Nurse #1, who was the nursing supervisor, was interviewed and stated that Resident #40 was found with a lit cigarette in their pocket on 09/12/2024. They stated the nursing supervisors are responsible for revising the care plan and that no new intervention was added to Resident #40's smoking care plan after the 09/12/2024 incident. On 03/19/2025 at 2:09 PM, the Director of Nursing was interviewed and stated they became aware of the incident on 09/12/2024. They stated that the nursing supervisor is responsible in updating the care plans and that there was no new intervention added to Resident #40's smoking care plan after the 09/12/2024 incident. 10 NYCRR 415.11(c)(2)(i-iii)

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected multiple residents

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Based 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. The findings are: The facility's policy titled Examination of Survey Results with a reviewed date of 01/2025 documented that survey reports and plans of correction are readily accessible to the residents, family members, resident representatives and to the public. A copy of the most recent survey report and any plans of correction are kept in a binder in the lobby. Survey reports, certifications, complaint investigations and plans of correction for the preceding three years are available for any individual to review upon request. Information containing the right to examine, the location of and how to request preceding years' survey reports and plans of correction are posted on the resident bulletin board and at each nurses' station. Inquiries concerning the examination of survey results should be referred to the administrator and/or to the Director of Nursing. During multiple observations on 03/12/2025 and 03/13/2025, there were no notices of availability of the survey results posted throughout the facility including the facility lobby was observed. On 03/14/2025 at 9:16 AM, a binder labeled Survey Results was observed inside the security office. On 03/14/2025 at 2:59 PM, an observation of the facility lobby, reception area, and security office was performed with the Director of Recreation and the Director of Nursing. A binder labeled Survey Results was observed on the wall inside the security office. The Activities Director stated that the security staff will provide the binder to anyone who asks to view it. There was no notice of availability of the survey results posted in the facility lobby, reception area, or the security office. The minutes of the Resident Council Meetings for the months of December 2024, January and February 2025 had no documentation that the resident council was informed of the availability and location of the most recent New York State Department of Health survey reports and plans of correction. On 03/14/2025 at 2:15 PM, during the Resident Council Meeting, Residents #13, #32, #36, #58, #76, #79, #100, #109, #123 stated they did not know where to find the survey results in the facility and they have not seen any notice telling them where to find such reports. On 03/14/2025 at 3:05 PM, the Director of Nursing was interviewed and stated that the binder containing the survey results and the notice of its availability were previously located on the wall in front of the reception/security office but over the weekend, the painters removed the posting and were not replaced. On 03/14/2025 at 3:16 PM, the Administrator was interviewed and stated that a signage of the availability of the survey results and a binder containing the survey results should have been placed by the security desk which would provide access to all visitors and residents. The Administrator stated that no one should have to ask to view the survey results as they should be easily accessible and readily available. The Administrator further stated that the binder containing the survey results, and the sign of the availability was removed for renovations and was not put back in the same place as staff was instructed to do. 10 NYCRR 415.3(d)(1)(vi)

Jun 2023 5 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are: The facility's policy titled Urinary Catheter Care dated 02/23/23 did not document privacy bag use for FC. Resident #46 had diagnosis of urinary retention and benign prostatic hyperplasia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #46 had mild cognitive impairment, required extensive assistance to transfer,and had an indwelling catheter. On 06/13/23 at 11:09 AM and 12:14 PM, Resident #46 was observed in a wheelchair in the hallway on their unit. Tubing was observed connecting Resident #46 to a FC drainage bag hanging from the back of the chair. The FC bag was not in a privacy bag. The Physician's order dated 06/11/23 documented Resident #46 had a suprapubic catheter for obstructive uropathy. The Comprehensive Care Plan (CCP) related to alteration in bowel and bladder initiated 10/18/17 documented Resident #46 had an indwelling FC. On 06/20/23 at 08:54 AM, Certified Nursing Assistant (CNA) #1 was interviewed and stated they assist Resident #46 with FC care. CNA #1 places the FC bag into a privacy bag and puts the tubing through the resident's clothing when the resident is placed in the wheelchair. Resident #46 does not refuse to wear the privacy bag. There was a day last week that Resident #46's FC was not in the privacy bag and CNA #1 reported it to the nurse because the resident's FC should have been in once. CNA #1 could not explain the reason Resident #46's FC was not in a privacy bag. On 06/20/23 at 12:21 PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated they monitor catheter care and the CNA is responsible or emptying the FC drainage bag. The FC bag should be in a privacy bag while the resident is in bed and a leg bag when out of bed. Resident #46 uses a leg bag when they are out of bed. The nursing supervisor monitors the use of privacy bags for FC. On 06/21/23 at 10:43 AM, Registered Nurse (RN) #1 was interviewed and stated they expect the staff to put a resident's FC in a privacy bag when the resident is in the bed and when the resident is out of bed the FC drainage bag should be replaced with a leg bag. RN#1 reported they did not notice that Resident #46 did not have a privacy bag on 6/13/23. 415.5(a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are: The facility policy titled Environment Care Services dated 02/2023 documented regular environmental care rounds will be conducted to identify and address any broken equipment, furniture and other potential hazards that may affect the well- being and safety of the individuals within the facility. On 06/21/23 11:24 AM, Resident # 83 was interviewed and stated they were unhappy with the state of their room. The blinds didn't work well and they did not like having mismatched floor tiles and patches of different colored wallpaper. Resident # 83 stated they complained to staff about the issues and was told the facility would take care of them, but nothing was done. On 06/13/2023 at 10 AM and 06/20/23 at 10:10 AM, the following were observed: a) Unit 1 - room [ROOM NUMBER] was observed with missing multiple blind blades, gray tape surrounded the windows, and the windows sills were dusty; b) Unit 3 - Shower Room was observed with rusty radiator covers, radiator metal grills were coiled inside, grills had white spackled paints in multiple areas, and the metal grills were dusty with black debris around it; c) Unit 3 - Shower Room was observed with mismatching floor tiles, dirty floor, and mismatching paints on the walls. There was no documented evidence environmental concerns on Unit 1 and Unit 3 were reported in the Maintenance Book. On 06/21/23 10:38 AM, Unit 3 Housekeeper was interviewed and stated they clean the shower room daily, sweep and mop all the rooms, wipe down the room furniture, and if something is broken, they use the Maintenance Logbook to write down the issue. Someone in Maintenance checks the book daily. On 06/21/23 11:09 AM, the Certified Nurse Aide (CNA) #2 was interviewed and stated that there is a Maintenance Logbook on the unit for the staff to write what needs repairing on the unit. CNA stated that if a curtain is missing, they tell the nurse on the floor or sometimes they write the problem in the maintenance book. On 06/21/23 11:50 AM Licensed Practical Nurse (LPN) #1 was interviewed and stated that the facility has an ongoing painting project and if a specific room needed attention or if they saw something not working they call the maintenance to get it fixed. How long it takes to fix depends on maintenance's workload. Requests go in the maintenance book and calls them for urgent matters. On 06/21/23 11:47 AM Director of Housekeeping and Maintenance stated they work on projects all over the building, such as buffing floors and changing blinds and curtains. The nurse calls them if there is a broken blind or dirty curtain, and they go to the floor and fix them. Director of Housekeeping and Maintenance also stated that they oversee replacing wallpaper and painting. There is a maintenance book where requests are put in for maintenance staff. 415.11

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are: The facility policy titled Wandering and Elopement dated 2/23 documented the safety and wellbeing of all residents with a potential for wandering is always ensured. The Aspen Complaint Tracking System (ACTS) intake documented that on 10/17/22 at 2:30PM, Resident #340 went down to the basement level via elevator and exited through an emergency exit door. Resident #340 was found by a staff member in the parking lot at 3PM and was returned to the facility without injury. No WAD was found on the resident. Review of the camera video footage revealed that staff pushed the button for the elevator from the basement level then had walked off when the elevator came to the basement. The identified staff was suspended, and the broken emergency exit door was serviced by the outside vendor. A facility tour was conducted with the Director of Facility Maintenance (DFM) on 6/21/23 at 9:45 AM. The emergency exit door in the basement was observed closed and tested to be functioning. The two elevators were observed to be locked to basement level, requiring a special key to be able to go to basement level. There were signage posted on the wall between two elevators in the basement level documenting to wait for the elevator to prevent possible elopement. Resident #340 had diagnoses of Alzheimer's disease and bipolar disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #340 had severely impaired cognition and did not exhibit wandering behavior. The Wandering/Elopement assessment dated [DATE] documented Resident #340 was at risk for wandering and elopement. The Medical Doctor Orders (MDO) initiated 8/19/22 and renewed 10/5/22 documented that Certified Nursing Assistant (CNA) checks for the WAD at the beginning and end of each shift, the nurse checks for WAD placement every shift, and the supervisor checks functioning of the WAD once daily. The Comprehensive Care Plan (CCP) related to wandering initiated 8/20/22 and last revised 10/17/22 documented interventions to encourage Resident #340 to engage in group activities/attempt to keep occupied, alert staff regarding the resident exhibiting behavior, provide a picture of the resident to the front desk, assist in re-orienting to their room, periodical check for functioning of WAD, WAD check every shift (removed by resident), visually monitor resident's location every hour, check ID bracelet, and WAD placement to the resident's left ankle. The MDO initiated 8/23/22, renewed 10/5/22 documented to place WAD #2863 on Resident #340's right arm. It was revised 10/17/22 and documented to place the WAD to left ankle. The Ancillary Administration Record from 8/19/22 to 10/17/22 documented Resident #340 had their WAD function checked daily. The hourly monitoring form dated 10/17/22 documented Resident #340 was visually checked by the CNA at every hour. On 6/21/23 at 9:26 AM, the Director of Facility Management (DFM) was interviewed and stated Resident #340 exited the building through an emergency exit door in the basement that led to the parking lot, The door is equipped with an audible alarm when someone presses on the crash bar. This notifies the security staff at the main entrance if there is an unauthorized exit. After 15 seconds of pressing on the crash bar, the emergency door unlocks allowing it to open in an emergency. The facility WAD system also alarms if a resident wearing a WAD is near the door. Resident #340 rode the elevator to the basement level and exited through the emergency door in the basement undetected. The alarm alert system did not activate when Resident #340 eloped through that door. The DFM further stated the basement is inaccessible to residents and the elevator locks if the basement button is pushed. Staff pushed the button for the basement, activating the elevator, and then walked off when the elevator came to the basement. Resident #340 got off the elevator, wandered off and eventually exited the facility to outside. DFM stated that the exit door was serviced immediately on the same day by the outside vendor. The staff member responsible for the elevator was suspended immediately after the incident. Staff in-services and posting of signage (by the basement elevator) for staff to wait for elevator to prevent resident eloping were reinforced. DFM stated that all exit doors are inspected and checked for functioning daily. On 6/21/23 at 11:24 AM, the Director of Nursing (DON) was interviewed and stated Resident #340 was discharged and does not reside in the facility. Resident #340 had no prior attempt of elopement but was assessed and identified as at risk for wandering and elopement. Because resident had history of removing the WAD, resident was monitored and visually checked every hour. Resident eloped undetected because the emergency door alarm system was down, and the resident's WAD was probably removed prior to leaving the facility. Resident #340 returned to the facility safely, without any injury and was noted without the WAD in place. A new WAD was placed on the resident and hourly monitoring was continued. The DON stated that one staff member was suspended, staff were [NAME]-serviced on elopement and all exit doors are checked daily by maintenance staff. 415.12(h)(1)(2) The facility was cited with a past non-compliance and the following Plan of Correction was implemented: For Resident #340: -Resident #340 was returned to the facility and assess with no visible injury -Resident #340 was educated against elopement and a new WAD was placed on the resident's left ankle. WAD functioning checks and hourly visual monitoring of resident were continued. -Entrance and all exit doors were inspected and fixed on 10/17/22. -CCP related to wandering and elopement was reviewed and revised on 10/17/22. -The Policy and Procedure on Elopement was reviewed by the DON and Administrator. No changes were made. -All staff were reeducated on Elopement Policy and Procedure. -Staff responsible to allow elevator to go to basement was suspended and later terminated. For all residents: -Reassessed all residents on elopement risk with wandering and history of exit seeking behaviors for WAD placement and were placed on hourly monitoring for safety. -Al residents are reassessed for elopement risk on quarterly basis. System Changes to prevent re-occurrence: -All elopement incidents will be reviewed to ensure all meet the criteria to ensure timeliness of reporting to DOH. -Episodic elopement drills conducted quarterly. -Exit doors are checked daily by the Maintenance department. -MD orders to reflect elopement risk, WAD placement/number/location and hourly monitoring. Monitoring efforts to prevent re-occurrence: -Quarterly audits were performed by DNS/Designee and as needed. -Audit findings were presented to Quality Assurance Performance Improvement (QAPI) Committee for evaluation and follow up as indicated. -Facility continued to reeducate staff on elopement policy and facility's drills. -DON/Designee monitoring of staff compliance with WAD/elopement prevention protocols and interventions quarterly.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #92 had diagnoses of vascular dementia and paranoid schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #92 had severely impaired cognition. Resident #99 had diagnoses of opioid abuse and coronary artery disease. The MDS dated [DATE] documented Resident #99 had severely impaired cognition. The facility's incident report initiated 4/27/23 documented Resident #92 and Resident #99 were involved in a physical altercation on 4/27/23 at 5PM. Resident #92 punched Resident #99 and then Resident #99 punched and pushed Resident #92. Resident #92 was noted with scant bleeding from the mouth and was transferred for evaluation and treatment. Resident #99 was noted with a bump on the forehead and bleeding from the mouth. Resident #99 was also transferred to the hospital for evaluation and treatment. Resident #92 was transferred to another unit upon returning from the hospital to prevent reoccurrence. The investigation was completed on 4/28/23 to conclude that there was no reasonable cause to believe that any alleged abuse occurred. The Aspen Complaint Tracking System documented the facility reported this allegation of physical abuse to NYSDOH on 4/28/23 at 12:18 PM, more than 2 hours after the incident occurred On 6/21/23 at 11:24 AM, the Director of Nursing (DON) was interviewed and stated the incident involving Resident #92 and Resident #99 occurred on 4/27/23 at 5PM. The investigation was initiated immediately and was completed on the following day. DON acknowledged that alleged incident was not reported to NYSDOH within 2 hours and was submitted on 4/28/23 at 12:18 PM. 415.4(b)(1)(i) Based 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. The findings are: The facility policy titled Abuse, Mistreatment, and Neglect dated 1/95 and updated 2/7/23 documented the Office of Health Systems Management (OHSM) will be notified immediately by administration, if in fact there is a reasonable cause to believe that an occasion of abuse, mistreatment, or neglect did occur, followed by a written report within 48 hours, on DOH 513, which is mailed to OHSM. 1) Resident # 43 had diagnoses of bipolar disorder and unspecified intellectual disabilities. The Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had moderately impaired cognition. Resident #117 had diagnoses of acute osteomyelitis and type 2 diabetes. The MDS dated [DATE] documented Resident #117 was cognitively intact. The facility's incident reported initiated 5/5/23 documented resident #43 and resident #117 were involved in a physical altercation on 5/5/23 at 10:05am. Resident #43 was sitting outside of residents #117 room. Resident #117 asked resident #43 to move and resident #43 did not. Resident #117 then hit the resident #43 with a chair. Staff reported they heard a loud scream and responded to Resident $43 bleeding. The Aspen Complaint Tracking System documented the facility reported this allegation of physical abuse to the NYSDOH on 5/5/23 at 2:38 PM, more than 2 hours after the incident. On 06/20/23 at 10:44 AM the Director of Nursing (DON) was interviewed and stated the incident involving Resident #117 and Resident #43 happened at 10:05am on 5/5/23. It was reported to the NYSDOH at 1:02 PM. The DON reported by the time the staff stabilize, interview, investigate, inform family, and then report the incident to the NYSDOH, it was over two hours. The DON reported the incident should have been reported within 2 hours.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected multiple residents

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Based 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. The findings include but are not limited to: The facility's policy titled MDS Comprehensive Assessment, Documentation Completion Policy dated 2/3/2023 documented the MDS Assessor/Coordinator submits MDS assessments that were completed timely to QIES to fulfill Federal regulations. The QIES CMS Submission Report dated 06/12/2023 documented the following MDS information: (1) The MDS assessment for Resident #75 documented Assessment Reference Date (ARD) of 05/05/2023, Completion Date of 05/18/2023 and Transmission Date of 06/12/2023. The Transmission Date was more than 14 days after Completion Date. (2) The MDS assessment for Resident #10 documented Assessment Reference Date (ARD): 05/12/2023, Completion Date: 05/24/2023 and Transmission Date: 06/12/2023. The Transmission Date was more than 14 days after Completion Date. (3) The Annual MDS assessment for Resident #128 documented Assessment Reference Date (ARD): 05/12/2023, Completion Date: 05/22/2023 and Transmission Date: 06/12/2023. The Transmission Date was more than 14 days after Completion Date. On 06/21/2023 at 11:21 AM, the MDS Coordinator was interviewed and stated of the 25 resident MDS data requested by the NYSDOH, 24 had MDS assessments that were submitted late. The MDS Department has had staffing issues and is doing the best they can. The MDS Coordinator takes full responsibility for late MDS submissions and is responsible for monitoring and ensuring that all MDS assessments are submitted timely by running a report for missing assessments. MDS Coordinator further stated they work with another facility to submit the MDS assessments in batches to QIES. The MDS department has a plan to address assessment submissions. The MDS Coordinator stated they are aware there are concerns with timely MDS submissions. 415.11

Apr 2021 6 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based 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). The findings are: The facility's policy and procedure entitled Medicare Determination and Notification, last revised 10/14/2019, states that a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) -- if the resident is staying in the facility -- will be provided to the resident or responsible party at least 2 days prior to the last day of skilled services. Resident #129 received Medicare Part A covered services which ended on 4/2/21 with 59 Medicare days left. The resident planned to remain in the facility for long term care. The resident received and signed a Notice of Medicare Non-Coverage (NOMNC) notice. The resident was not provided with a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) notice. On 4/30/2021 at 12:16 PM, an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated she did not provide Resident #129 with an ABN because she did not think it was necessary as there was a waiver. The MDS Coordinator presented a document titled Medicare Waiver 1135 COVID dated 2/21/21 which stated that the physician had decided with the resident's and family's agreement to treat the resident in place rather than transferring the resident to the hospital for acute pneumonia. The MDS Coordinator stated that based on that that situation she did not think ABN letters were required for discharges from skilled services and so did not issue one. On 04/30/21 at 11:07 AM, an interview was conducted with the Corporate Director of Resident Assessment (DRA) The DRA stated that the COVID waiver document that the MDSC referred to had nothing to do with serving an ABN and the resident should have been provided with the appropriate notice. 415.3 (g)(2)(i)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) The findings are: Resident # 71 was admitted to the facility with diagnoses that included Cerebrovascular Accident, Hypertension, Hemiplegia and Schizophrenia. On 4/26/21 at 11:10 AM, Resident #71 was greeted in the hallway. Resident was not able to hear the surveyor's questions and asked the surveyor to repeat self. Resident reported not being able to hear and shrugged shoulders when asked about a hearing aide. On 4/26/21 at 3:23 PM, an interview was conducted with Resident #71 in the Conference Room. The resident requested the surveyor speak louder and repeat questions because of difficulty hearing. The resident was not wearing a hearing aid. Resident also stated an evaluation had been a long time ago and hearing aids had never been received. The Quarterly Minimum Data Set (MDS) dated [DATE] documented resident was cognitively intact and had moderate hearing difficulty (speaker has to increase volume and speak distinctly) and no hearing aid or other hearing appliance used. The Comprehensive Care Plan titled Communication initiated 8/19/2016 and revised on 3/7/21 documented moderate hearing difficulty. Speaker has to increase volume and speak distinctly. Also give time to verbalize thoughts. Goal was resident will continue to communicate needs to staff for 90 days. Interventions include increase volume as needed and speak distinctly during communication with resident and look for signs of resident understanding on what is being said. There was no care plan that included goals or specific interventions to address resident's hearing impairment. On 04/30/21 at 11:17 AM an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS stated that she is responsible for completing episodic care plans. Care plans are basically done by the MDS Coordinator. The RNS also stated that Resident #71 has hearing difficulty and you have to be close to her and speak loudly when communicating with her. The RNS further stated that the resident has no care plan for the hearing concern but should have. On 04/30/21 at 11:27 AM, an interview was conducted with the MDS Assistant. The MDS Assistant stated that she does all the MDS assessments and creates care plans. The RN Supervisors do the episodic care plans and I assist with the care plan updates. There is someone who works part-time 3 times a week and she also assists with care plans. Resident #71 has some hearing loss; you have to talk loud to the resident and go very close when speaking to the resident. The resident does have a communications care plan which was done together with Social Services but there are no goals and interventions specific to hearing such as go to ENT. The MDS Assistant stated she would have been responsible for ensuring the care plan had the appropriate goals and interventions. On 04/30/21 at 11:41 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the primary responsibility for care plans lies with the MDS department. The RN supervisor can assist with episodic care plans or when there are incidents or changes with resident. A care plan should include the problems, goals, and interventions and goals and interventions should be reflective of the problem. The ADON stated that interventions for a resident with hearing impairment should include speaking loudly, speaking in front of the resident, and assessing for need of aids. On 04/30/21 at 03:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated once the MDS department completes the assessment, they create the Comprehensive Care Plan (CCP). The CCP should be based on the care area assessments that trigger, along with anything clinical and psychosocial and should include goals and interventions that address all the resident's concerns. The assessment by the licensed nurse is the opportunity to identity concerns of the resident and if concerns are identified a care plan should be created. The DON stated that on occasion, he would do spot checks of care plans when there is an incident with the resident or when issues are presented in the morning meeting. 415.11 (c)(1)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) The findings are: The facility policy and procedure titled Consults dated September 2020 documented the facility would provide every resident a proper care and provide best consultant that suited to their need in a timely manner. The policy also documented that consults may be ordered as indicated by a resident's condition, primary physician will order subsequent consults and follow-ups as needed and consults must be completed within 30 days, otherwise will either be reordered or discontinued as per primary physician's order. Resident # 71 was admitted to the facility with diagnoses that included Cerebrovascular Accident, Hypertension, Hemiplegia and Schizophrenia. On 4/26/21 at 11:10 AM, Resident #71 was greeted in the hallway. Resident was not able to hear the surveyor's questions and asked the surveyor to repeat self. Resident reported not being able to hear and shrugged shoulders when asked about a hearing aide. On 4/26/21 at 3:23 PM, an interview was conducted with Resident #71 in the Conference Room. the resident requested the surveyor to speak louder and repeat questions because of difficulty hearing. The resident was not wearing a hearing aid. Resident also stated an evaluation had been done a long time ago and hearing aids had never been received. The Quarterly Minimum Data Set (MDS) dated [DATE] documented resident was cognitively intact and had moderate hearing difficulty (speaker has to increase volume and speak distinctly) and no hearing aid or other hearing appliance used. MDS assessments completed on a quarterly basis dated 2/15/20 to 2/26/21 documented that resident had moderate hearing difficulty. Initial Audiology Report dated 2/25/20 documented resident was referred for complaint of hearing difficulty. Recommendations included ENT for medical clearance for hearing aids/cerumen removal, hearing aid eval (evaluation), Audio to monitor annually, communication strategies (sheet provided). Physician Orders dated 3/13/20 documented Otorhinolaryngology follow-up. The order was renewed monthly from 3/20/20 to 7/26/20 before being discontinued on 7/26/20. Physician Orders dated 7/26/20 documented Otorhinolaryngology follow-up for recurring epistaxis (nosebleeds). Please call to reschedule appt (appointment). The order was renewed monthly from 8/16/20 to 3/30/21. Physician Order dated 8/13/20 documented Carbamide Peroxide 6.5% ear drops instill 5 drops by otic (ear) route in each ear 2 times per day for 7 days for impacted cerumen. Order was discontinued on 8/20/20. There was no documented evidence that audiology follow-up was provided after the initial audiology evaluation on 2/25/20 and after treatment for cerumen removal in August 2020. On 04/30/21 at 11:02 AM, an interview was conducted with Certified Nursing Assistant (CNA) #3. CNA #3 stated resident has difficulty hearing and in order to communicate with her you have to go very close to the resident and speak loudly. CNA#3 also stated the resident does not have a hearing aide. On 04/30/21 at 12:11 PM, an interview was conducted with the Attending Physician (AP). The AP stated that she has been assigned to the unit for over a year and the first thing that struck her about Resident #71 was the resident's hearing impairment and in order to communicate with the resident she had to speak very loudly. The AP also stated there was no audiology consultant on site so resident had to be sent out and an order was entered for the resident to be seen on more than one occasion but the order was no longer valid and resident had not been seen. The AP also stated that following a change in ownership, the previous consultants were no longer available and she entered an order for resident to be seen by ENT (Ear, Nose, Throat) Specialists and even though the consult specified epistaxis, she had hoped the resident's hearing would be evaluated. The AP stated that the order had not been followed up on, and the resident had not been seen for audiology services. On 04/30/21 at 12:42 PM, an interview was conducted with the Medical Director (MD). The MD stated that all resident care needs should be followed up on by the Attending Physicians during visits. The MD also stated that a resident with a hearing impairment should be accommodate and ensure that assistive devices are provided if required. The MD further stated that the resident could have been provided with an amplifier of some sort in the interim while audiological services are pending. 415.12 (3)(b)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) The findings are: The facility policy and procedure titled Physician Services revised on 9/14/20 documented the responsibilities of the attending physician included a review of the resident's total program of care, including medications and treatments, at each regularly scheduled visit, including reasons for changing or maintaining current treatments or medications, and a plan to address relevant medical issues. Resident # 71 was admitted to the facility with diagnoses that included Cerebrovascular Accident, Hypertension, Hemiplegia and Schizophrenia. On 4/26/21 at 11:10 AM, Resident #71 was greeted in the hallway. Resident was not able to hear the surveyor's questions and asked the surveyor to repeat self. Resident reported not being able to hear and shrugged shoulders when asked about a hearing aide. On 4/26/21 at 3:23 PM, an interview was conducted with Resident #71 in the Conference Room. The resident requested the surveyor speak louder and repeat questions because of difficulty hearing. The resident was not wearing a hearing aid. Resident also stated an evaluation had been done a long time ago and hearing aids had never been received. The Quarterly Minimum Data Set (MDS) dated [DATE] documented resident was cognitively intact and had moderate hearing difficulty (speaker has to increase volume and speak distinctly) and no hearing aid or other hearing appliance used. MDS assessments completed on a quarterly basis dated 2/15/20 to 2/26/21 documented that resident had moderate hearing difficulty. Initial Audiology Report dated 2/25/20 documented resident was referred for complaint of hearing difficulty. Recommendations included ENT for medical clearance for hearing aids/cerumen removal, hearing aid eval (evaluation), Audio to monitor annually, communication strategies (sheet provided). Physician Orders dated 3/13/20 documented Otorhinolaryngology follow-up. The order was renewed monthly from 3/20/20 to 7/26/20 before being discontinued on 7/26/20. Physician Orders dated 7/26/20 documented Otorhinolaryngology follow-up for recurring epistaxis (nosebleeds). Please call to reschedule appt (appointment). The order was renewed monthly from 8/16/20 to 3/30/21. Physician Order dated 8/13/20 documented Carbamide Peroxide 6.5% ear drops instill 5 drops by otic (ear) route in each ear 2 times per day for 7 days for Impacted cerumen. Order was discontinued on 8/20/20. NP note dated 2/26/20 documented patient was seen for follow-up Audiology eval. Patient went to audiology for evaluations of sensorineural hearing loss bilateral and they recommend to ENT for consult for medical clearance/cerumen management and she needs hearing aid. The note also documented that appointment was scheduled for 4/7/20. Review of the MD Monthly Progress notes dated 3/18/20- 7/14/20 contained no documentation regarding the resident's hearing impairment. Attending Physician note dated 7/24/20 documented ENT evaluation was re-ordered as resident has a history of frequent epistaxis. Continue current regimen pending ENT follow-up. Monthly MD Progress Summary dated 8/13/20 documented resident was seen for decreased hearing: suspected cerumen. Ear drops ordered for 7 days. Physician's Progress notes dated 9/15/20 to 4/1/21 contained no documented evidence that resident's hearing impairment was addressed even though review of systems documented resident was HOH (hard of hearing). There was no documented evidence that the resident's total program of care was reviewed at each visit. On 04/30/21 at 11:02 AM, an interview was conducted with Certified Nursing Assistant (CNA) #3. CNA #3 stated resident has difficulty hearing and in order to communicate with the resident you have to go very close to the resident and speak loudly. CNA#3 also stated the resident does not have a hearing aide. On 04/30/21 at 12:11 PM, an interview was conducted with the Attending Physician (AP). The AP stated that when doing monthly notes she reviews the communication book for any concerns that may have been documented by other disciplines. In addition, she reviews lab results and any consults that may have been done and need to be followed up on. The AP also stated that she was aware of the resident's hearing impairment as she would she have to raise her voice when speaking to the resident. The AP further stated that she had put orders in for audiology services but due to the lockdown residents were not going to appointments. A change in ownership meant that the previous consultants were no longer available. The AP also stated she did not have any evidence that appointments had been scheduled and cancelled due to COVID-19 and that the resident's hearing impairment was not something that she addressed in her monthly notes although the resident's hearing concerns were not yet resolved. On 04/30/21 at 12:42 PM, an interview was conducted with the Medical Director (MD). The MD stated that all resident care needs should be followed up on by the Attending Physicians during visits. The physician should be reviewing medication, any changes in resident's status, reviewing consultant reports and recommendations and ensuring all areas are addressed. Resident care concerns should be followed up on and when consultants are no longer available, we would seek out providers who can provide the services our residents need. 415.15 (b)(2)(iii)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) The findings are: During multiple observations on Unit 2 between 4/26/21 at 10:05 AM and 4/30/21 at 1:00 PM, the following were observed but not limited to: room [ROOM NUMBER]- broken blinds. Both overbed tables were soiled with a brown dried on substance. room [ROOM NUMBER]- laminated edge missing from tray table, tray table soiled with a brown dried on substance. room [ROOM NUMBER]- mismatched and broken blinds. room [ROOM NUMBER]- towel placed under sink. Sink leaked when faucet was turned on. Soiled and mis-hung privacy curtains. room [ROOM NUMBER]- broken tiles in bathroom, duct tape around windows, mis-hung privacy curtains. Cracked plaster was observed on the ceiling between room [ROOM NUMBER] and 205. room [ROOM NUMBER]-mishung privacy curtains. room [ROOM NUMBER]- dark, grey substance resembling fungus on wall between 2 stuffed toys. Mis-hung privacy curtains. In 2nd Floor dayroom, 2 stools were observed with cracked upholstery. Bathroom opposite room [ROOM NUMBER]-212 strips of black duct tape over shower stall nearest window which had water-stained ceiling with cracked plaster. Loose tiles were observed hanging over window. Missing tile was observed behind the toilet. The pull-string was missing from the call light. Review of 2nd Floor Maintenance log book entries from September 2020 to present contained no documentation regarding any of the above concerns. On 04/30/21 at 11:14 AM, a resident who resided in room [ROOM NUMBER] stated a towel has been placed under the sink for about a year and was placed there by the resident because the sink was leaking. On 04/30/21 at 01:16 PM, Housekeeper (HSK) #1 was interviewed with Housekeeper #2 acting as an interpreter. HSK #1 stated that his duties on the floor included, sweeping mopping on the 2E side of Unit 2. HSK#1 also stated if items are broken, he tries to tell the maintenance guys. HSK#1 further stated that the Certified Nurse's Assistants clean the overbed tables but if he sees it is dirty, he will clean. He stated that he saw the overbed table and broken blinds but did not report it to his supervisor. He did notice the mis-hung privacy curtains and so did not report any issues to his supervisor. On 04/30/21 at 01:28 PM, an interview was conducted with the Director of Facilities Management (DOFM). The DOFM stated that he monitors work of his staff by going to floor and making rounds. He ensures that staff is at their work stations and observes to see that rooms have cleaned, which includes making observations of everything from curtains to windows, to water in the sinks and bathrooms. The DOFM also stated that he encourages his staff to report all issues and send him pictures of issues that need attention. Broken window blinds and leaking sink should have been reported and acted on. The DOFM further stated that the stools should have been removed and replaced, and additional privacy curtains had to be ordered so we can change the ones that are currently hanging. 415.5 (h)(2)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

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Based 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. On 04/29/2021 at 02:36 PM, the Assistant Food Service Director (AFSD) was interviewed. The AFSD stated the garbage compactor with the door left open is for cardboard. The kitchen staff usually use the other garbage compactor for refuse. The AFSD also stated all compactor doors should be kept closed. On 04/29/2021 at 02:46 PM, the Director of Facilities Management (DOFM). The DOFM stated both housekeeping and kitchen staff use both garbage compactors. Housekeeping brings garbage down once daily. Cardboard goes on the left side of the compactor, and the right side is for other garbage. The DOFM also stated the doors are supposed to be kept closed to keep pests and animals out. The DOFM further stated staff is expected to keep compactor closed and the compactors are not monitored on a daily basis to ensure that they are kept closed. 415.14(h)

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 30% annual turnover. Excellent stability, 18 points below New York's 48% average. Staff who stay learn residents' needs.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s), $93,279 in fines. Review inspection reports carefully.
• 22 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• $93,279 in fines. Extremely high, among the most fined facilities in New York. Major compliance failures.
• Grade F (23/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is New Riverdale Rehab And Nursing's CMS Rating?

CMS assigns NEW RIVERDALE REHAB AND NURSING an overall rating of 2 out of 5 stars, which is considered below average nationally. Within New York, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is New Riverdale Rehab And Nursing Staffed?

CMS rates NEW RIVERDALE REHAB AND NURSING's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 30%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 55%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at New Riverdale Rehab And Nursing?

State health inspectors documented 22 deficiencies at NEW RIVERDALE REHAB AND NURSING during 2021 to 2025. These included: 1 that caused actual resident harm, 20 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates New Riverdale Rehab And Nursing?

NEW RIVERDALE REHAB AND NURSING is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CITADEL CARE CENTERS, a chain that manages multiple nursing homes. With 146 certified beds and approximately 138 residents (about 95% occupancy), it is a mid-sized facility located in BRONX, New York.

How Does New Riverdale Rehab And Nursing Compare to Other New York Nursing Homes?

Compared to the 100 nursing homes in New York, NEW RIVERDALE REHAB AND NURSING's overall rating (2 stars) is below the state average of 3.1, staff turnover (30%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting New Riverdale Rehab And Nursing?

Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.

Is New Riverdale Rehab And Nursing Safe?

Based on CMS inspection data, NEW RIVERDALE REHAB AND NURSING has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New York. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at New Riverdale Rehab And Nursing Stick Around?

Staff at NEW RIVERDALE REHAB AND NURSING tend to stick around. With a turnover rate of 30%, the facility is 16 percentage points below the New York average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.

Was New Riverdale Rehab And Nursing Ever Fined?

NEW RIVERDALE REHAB AND NURSING has been fined $93,279 across 4 penalty actions. This is above the New York average of $34,012. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is New Riverdale Rehab And Nursing on Any Federal Watch List?

NEW RIVERDALE REHAB AND NURSING is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 146
Avg. Residents: 138
Occupancy: 94.9%
Ownership: For profit - Limited Liability company
Chain: CITADEL CARE CENTERS
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
Low Turnover: +3
1 Actual Harm citation: -5
22 Deficiencies: -10
Fines ($93,279): -10
Abuse Finding: -15
Final Score: 23/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 335096