Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adira At Riverside Rehabilitation And Nursing during CMS and state inspections, most recent first.
Two residents with ventilator dependence, severe cognitive impairment, and multiple pressure ulcers did not receive wound care consistent with practitioner orders and accurate clinical information. For one resident, the wound nurse independently increased the frequency of wound treatments beyond the wound specialist’s daily order, implementing twice-daily and three-times-daily treatments in response to excessive drainage and purulent discharge without the practitioner’s knowledge. For another resident, progressive leukocytosis and an infected buttock ulcer were documented, IV antibiotics were started then discontinued before completion, and a discrepancy arose between the wound specialist’s documented order for Silvadene and the wound nurse’s documentation and transcription of Santyl instead. This resident’s condition worsened, with rising WBCs, severe anemia requiring hospital transfer, and a wound culture showing multiple organisms, while hospital staff were unable to obtain detailed information from facility nursing staff about the change in condition.
Two residents at high risk for pressure ulcers did not receive care consistent with professional standards. One ventilator-dependent resident with multiple facility-acquired stage 2 and 3 sacral and buttock ulcers had weeks of documented stagnant, draining wounds and an infected ulcer without evidence of care plan revision or treatment changes, and CNA records showed the resident remained in the same position in bed for extended periods. Another ventilator-dependent resident admitted with an unstageable sacral ulcer and identified as high risk for skin breakdown had a care plan calling for q2h turning, skin monitoring, and pressure-relieving devices, but there was no documentation of timely offloading device evaluation or follow-up wound consult, and CNA records initially lacked evidence of q2h repositioning; within a short time, this resident developed multiple new deep tissue injuries and a hip abrasion.
Two ventilator‑dependent residents with multiple pressure ulcers and complex medical needs did not have their total programs of care reviewed by an attending physician at required visits. For one resident, wound documentation and interviews showed discrepancies between the wound specialist’s recommended treatments and the pulmonologist’s signed orders, with no evidence that the physician reconciled or evaluated these differences despite ongoing purulent drainage and increased treatment frequency. For another resident, serial wound notes documented stagnant, draining sacral and buttock ulcers and labs showed progressively abnormal WBC, Hgb, and Hct values, while NPs ordered and adjusted antibiotics and topical treatments; however, the pulmonologist’s monthly note only mentioned pressure ulcers without addressing their unhealing status or abnormal labs. Interviews with the DON, NPs, medical director, pulmonologist, and administrator revealed conflicting understandings of who was the attending physician for ventilator‑dependent residents, and there was no clear physician oversight of the residents’ overall care, leading to the cited deficiency.
Surveyors found that wound care services did not meet professional standards when a wound nurse independently altered wound treatment orders for two residents with multiple pressure ulcers. For one resident with severe cognitive impairment and ventilator dependence, the nurse transcribed and implemented wound care at higher frequencies than ordered by the wound specialist, based on observed excessive drainage. For another resident with advanced neurologic impairment and facility-acquired pressure ulcers, the nurse documented and transcribed a change from Silvadene to Santyl ointment for a buttock ulcer that was not reflected in the wound specialist’s written order. The ADON reported limited recall of the nurse’s wound care competency and noted that nurses on the vent unit routinely provided more-than-daily dressing changes due to soiling, despite wound care being expected to follow specialist recommendations.
A resident with severe cognitive impairment, ventilator dependence, and multiple pressure ulcers, including an infected buttock ulcer on contact precautions, received wound care during which infection control practices were not followed. A nurse removed dressings from multiple wounds while the resident lay on a towel that became soaked with drainage, and no barrier or drop cloth was placed between the resident’s open wounds and the contaminated towel. When the nurse stepped away, a CNA allowed the resident to drop back so that sacral and buttock wounds directly contacted the soiled towel. The nurse later admitted forgetting to use a barrier, and the Assistant DON, who shared infection control responsibilities, reported not having observed the nurse’s wound care practices, despite an expectation that barriers be used to prevent wound contact with potentially soiled surfaces.
A resident with severe cognitive impairment and multiple comorbidities sustained a head injury after falling from bed when a CNA turned the resident away from themselves during in-bed care, contrary to facility policy. The CNA did not call for assistance and was unable to prevent the fall, resulting in the resident being transferred to the hospital with a laceration, hematoma, and further complications identified on imaging.
A resident at high risk for pressure ulcers developed an unstageable ulcer due to the facility's failure to update care plans and implement necessary interventions. Despite the resident's left heel redness being identified, staff did not ensure proper off-loading, turning, and repositioning. Observations showed the resident's heels were not elevated, and there was inadequate documentation and communication regarding care. This led to the deterioration of the resident's skin integrity, resulting in actual harm.
The facility was found to have insufficient nursing staff, resulting in delayed responses to call bells and residents being unable to get out of bed when desired. Residents reported these issues during interviews and a Resident Council meeting, with specific instances of long waits for bathroom assistance and missed therapy sessions. Staffing sheets showed understaffing on 19 out of 31 days, and staff confirmed frequent double shifts to cover absences.
The facility did not conduct annual performance reviews for CNAs, as required. Eight CNAs, employed for over a year, lacked documented evaluations. Staff responsible for these evaluations could not explain the oversight, as confirmed through interviews and record reviews.
A resident with pneumonia, chronic respiratory failure, and dementia was not promptly reported to their representative about a pneumonia diagnosis and antibiotic treatment initiation. The facility's policy required such notifications, but there was no evidence of compliance. Interviews indicated that nurses were responsible for family notifications, yet the expected communication did not occur.
A resident with severe cognitive impairment and a history of pressure injuries developed a pressure injury on the left heel, but the care plan was not updated with necessary interventions. Despite being at high risk, the resident's heels were not off-loaded or elevated, and they were not repositioned regularly. Staff interviews confirmed that the wound progressed to an unstageable state, and preventative measures were not implemented promptly.
The facility failed to provide necessary care and equipment for residents with limited range of motion, as three residents were observed without their prescribed hand rolls. Despite care plans and physician orders, staff interviews revealed a lack of awareness and communication, leading to the residents not receiving the intended interventions to prevent contractures and maintain skin integrity.
A resident with chronic respiratory failure was observed receiving oxygen therapy at a higher flow rate than prescribed. Despite physician orders for 2-3 liters per minute, the resident was receiving 4 to 4.5 liters per minute. Staff documented adherence to the prescribed rate, but a nurse later adjusted the flow to the correct rate, unable to explain the initial discrepancy.
The facility failed to maintain food safety standards, with expired sandwiches found in the refrigerator and on lunch trays, and residents' personal food stored beyond the allowed limit. Additionally, the first-floor ice machine was unclean, with black slime observed inside. The Assistant Food Service Director and Director of Housekeeping acknowledged these issues, highlighting lapses in adherence to food safety protocols and cleaning schedules.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in infection tracking, Legionella water management, staff vaccination education, and implementation of Enhanced Barrier Precautions for residents. The Infection Preventionist did not track infections in real-time, and the Water Management Plan had not been updated since 2016. Staff were not educated about pneumonia vaccination, and necessary precautions for residents were not properly implemented.
A facility failed to document offering and educating a resident on pneumococcal immunization, as required by policy. The resident, with respiratory failure and ventilator dependence, had no record of being offered or declining the vaccine. Interviews revealed disorganization in tracking vaccine information, with the Infection Preventionist lacking tools to monitor vaccine status and the DON acknowledging the need for better tracking.
The facility failed to document and educate a resident and a staff member on COVID-19 vaccination, lacking records for a ventilator-dependent resident and a staff member. Interviews revealed systemic issues in tracking vaccination records, with staff not being approached about their vaccine status or offered boosters.
Failure to Provide Ordered and Accurately Managed Wound Care for Residents With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents with pressure ulcers received treatment and care according to practitioner orders and accurate clinical information. For one resident with chronic respiratory failure, ventilator dependence, severe cognitive impairment, and multiple pressure ulcers (three present on admission and one facility-acquired), the facility’s wound care nurse independently increased the frequency of wound treatments beyond what the wound care physician assistant had ordered. The wound PA had ordered daily and PRN treatments to multiple pressure ulcers, but the wound nurse transcribed and implemented orders for twice-daily and three-times-daily treatments, documenting and carrying them out over several days. The wound nurse reported that the change was made due to excessive drainage and purulent discharge from a buttock wound and that the resident had experienced excessive drainage for at least a week, but the PA stated they had not recommended more than once-daily treatment and were not aware of the excessive drainage. For another ventilator-dependent resident with severe cognitive impairment and facility-acquired stage 2 and 3 pressure ulcers, the facility did not accurately transcribe wound specialist recommendations and did not thoroughly review and address signs of worsening infection. Laboratory results showed a progressively increasing white blood cell count over several dates, and a nurse practitioner documented an infected right buttock ulcer and ordered IV Zosyn and follow-up by the wound care team. The antibiotic was discontinued before completion after a negative urinalysis, and later a wound PA documented an order for Silvadene to the right buttock ulcer, while the wound nurse’s note from the same day documented that the PA changed the treatment to Santyl ointment. The physician order transcribed by the wound nurse reflected Santyl rather than Silvadene. Subsequent lab results for this resident showed a further increase in white blood cell count, and the resident required transfer to the hospital for severe anemia and a blood transfusion. Hospital records documented a markedly elevated white blood cell count and a wound culture positive for multiple organisms, including Klebsiella pneumoniae, Proteus mirabilis, Acinetobacter, yeast, and staphylococcus species, and the resident was started on IV antibiotics. The hospital attempted, but was unsuccessful, in obtaining more information from facility nursing staff regarding the resident’s change in condition prior to hospitalization. Interviews with the wound nurse, DON, nurse practitioner, and pulmonologist showed that wound assessments, documentation of wound characteristics, and responsibility for monitoring and responding to changes in wound status were fragmented, with the wound nurse stating they did not document wound assessments and the DON stating nursing staff were responsible for daily wound documentation and referral of changes to the physician.
Failure to Revise Wound Care and Implement Pressure Ulcer Prevention for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer treatment and preventive care consistent with professional standards for two residents with significant skin integrity needs. One resident with chronic respiratory failure, ventilator dependence, severe cognitive impairment, and total dependence for ADLs had multiple facility-acquired stage 2 and 3 pressure ulcers to the sacrum and buttocks. Despite wound care notes over several weeks documenting that these ulcers were stagnant and producing moderate serous to serosanguinous drainage, there was no documented revision of the resident’s treatment plan to address the lack of healing or the ongoing drainage. A nurse practitioner documented that the right buttock ulcer was infected, yet subsequent wound notes continued to describe stagnant wounds with moderate serosanguinous drainage and no changes in measurements, characteristics, or treatment orders for the sacral and buttock ulcers. For this same resident, the facility’s documentation showed additional concerns with basic pressure relief and monitoring. The CNA accountability record for the month indicated the resident remained in the same position in bed for six or more hours on 15 of 25 days, despite the resident’s immobility and known pressure ulcers. The wound care nurse reported that they performed daily treatments and transcribed wound specialist orders into physician orders, but stated they did not document wound assessments until after the wound specialist had assessed the wounds. The DON, however, stated that nursing staff were responsible for documenting wound characteristics daily during treatment administration and referring any changes to the physician. There was no documented evidence that the wound care provider addressed the infected right buttock ulcer or reviewed and adjusted the care plan in response to the nonhealing, draining pressure ulcers. When the resident was transferred to the hospital for severe anemia, the hospital documented a large sacral ulcer with purulent drainage and a wound culture showing multiple organisms, and the sanguinous discharge from the sacral ulcer was described as highly suspicious as the source of the resident’s infection and anemia. The second resident was admitted with acute respiratory failure requiring ventilator support, a history of cerebrovascular accident, severe cognitive impairment, total dependence for ADLs, and an unstageable sacral pressure injury. Admission assessments and the MDS identified the resident as high risk for pressure ulcers, and the care plan called for skin risk assessment, preventive skin care, monitoring for changes each shift, keeping skin clean and dry, incontinent care every two hours, turning and repositioning every two hours, and providing appropriate pressure-relieving devices per PT/OT recommendations. A wound note documented an unstageable sacral ulcer and ordered Medi-honey with a follow-up wound consult in one week. However, there was no documented evidence that the resident was evaluated for offloading devices to prevent further breakdown, and no documentation that the wound care specialist saw the resident again within a week as planned. Within days of admission, nursing documentation showed the resident initially awake and responsive during perineal care and wound dressing, but later that same day another nurse documented a new abrasion to the left hip and multiple deep tissue injuries to both heels, both ankles, and the right hip. Physician orders were then written for a wound consult for these deep tissue injuries, bilateral heel boots, and topical treatments. Review of CNA accountability records for the admission month showed no documented turning and repositioning assistance in accordance with the care plan, with documentation of every-two-hour turning and positioning not appearing until later in the following month. Staff interviews revealed that CNAs relied on accountability records to determine which residents required turning and repositioning and had no place to document observed skin changes themselves, depending instead on licensed nurses to act on their verbal reports. The ADON later stated they had investigated the resident’s facility-acquired deep tissue injuries and concluded they were unavoidable, and also reported they could not recall the last time the wound care nurse had a wound care competency, while the facility lacked an inservice coordinator and relied on the wound care vendor for wound care education.
Failure to Ensure Physician Review of Total Care for Ventilator‑Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the attending physician reviewed each ventilator‑dependent resident’s total program of care, including medications, treatments, wound care, and abnormal laboratory results, at required visits. For one ventilator‑dependent resident with chronic respiratory failure, cerebral infarction, and multiple pressure ulcers (including one facility‑acquired), the face sheet identified a pulmonologist as the attending physician. A wound note dated 03/27/2026 ordered daily and PRN treatments to multiple ulcers, while physician orders signed by the pulmonologist on the same date specified different treatment frequencies (twice daily for some wounds and three times daily for others). The treatment administration record showed staff followed the pulmonologist’s orders, but there was no documented evidence that the pulmonologist, as attending physician of record, reviewed or reconciled the discrepancies between the wound specialist’s recommendations and the physician’s own treatment orders. Interviews and wound documentation for this resident showed ongoing wound problems that were not addressed by the attending physician. The wound care nurse reported that the resident had multiple wounds, including a right buttock wound with purulent discharge and signs of infection, and that the wound care specialist verbally recommended treatment orders during weekly wound rounds, which the nurse transcribed into physician orders and used to update the care plan. The nurse also stated that, due to excessive drainage, wound treatments had been increased from twice daily to three times daily for at least a week. However, the wound physician assistant stated they had not recommended treatments more than once daily and indicated they would have recommended hospitalization if they had known the resident required wound care more than once daily for excessive drainage. Subsequent medical notes contained no evaluation or discussion by the attending physician of these wound care changes or the wound team’s recommendations. For a second ventilator‑dependent resident with chronic respiratory failure, hypoxic ischemic encephalopathy, and multiple unhealed, facility‑acquired stage 2 and 3 pressure ulcers, the face sheet also listed the pulmonologist as the attending physician. This resident had stagnant, unhealing sacral and buttock ulcers with ongoing serosanguinous drainage documented in multiple wound notes. Laboratory results over time showed progressively abnormal values, including elevated WBC counts and low hemoglobin and hematocrit. Nurse practitioner notes documented an infected right buttock ulcer, initiation of IV Zosyn, and subsequent discontinuation of the antibiotic before completion, as well as additional wound treatment orders (Santyl and Silvadene). Despite these findings and repeated wound notes describing stagnant, draining ulcers, there was no documented evidence that the pulmonologist, as attending physician of record, reviewed or addressed the increasingly abnormal lab values or the ongoing reports of stagnant, draining, unhealing pressure ulcers. The pulmonologist’s monthly progress note referenced the presence of pressure ulcers but did not address their unhealing status or recent lab results. Interviews with facility leadership and clinicians revealed confusion and inconsistency regarding who was actually serving as attending physician for ventilator‑dependent residents. The DON stated that nursing staff were responsible for documenting wound characteristics daily and referring any changes to the medical doctor. A nurse practitioner reported that three NPs sometimes covered episodic concerns on the ventilator unit and that wound care specialists were responsible for evaluating wounds, addressing stagnant unhealing wounds, and ordering treatments. The medical director stated that the pulmonologist was assigned as attending physician for ventilator‑dependent residents and that facility clinicians, including the medical director and pulmonologist, were responsible for ensuring wound care specialists addressed the care plan and that orders were carried out. In contrast, the pulmonologist stated they were only responsible for respiratory care, were not the attending physician for any residents, and were not responsible for non‑respiratory treatments. The administrator similarly stated the pulmonologist was not the attending physician for ventilator‑dependent residents and was unaware of why the pulmonologist was listed as attending on the residents’ face sheets. This lack of clarity and failure to ensure that an attending physician reviewed and coordinated the residents’ total care programs led to the cited deficiency under 10 NYCRR 415.15(b)(2)(iii).
Failure to Follow Wound Specialist Orders and Professional Standards in Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that services met professional standards of quality for residents with pressure ulcers when wound treatment orders were not followed as prescribed by wound care practitioners. For one resident with chronic respiratory failure, ventilator dependence, severe cognitive impairment, and multiple pressure ulcers (three present on admission and one facility-acquired), the wound care physician assistant ordered daily and as-needed treatments to ulcers on the right mid-back, sacrum, right medial buttock, right lateral buttock, and left lateral leg. However, the wound care nurse transcribed these orders as more frequent than prescribed, documenting treatments to the mid-back and left lateral leg twice daily and to the sacral and buttock ulcers three times daily. Treatment records show that staff administered wound care at these increased frequencies until the resident’s subsequent hospitalization. The wound care nurse stated they independently changed the frequency of treatments due to observing excessive drainage and purulent discharge, while the wound care physician assistant stated they had not recommended treatment more than once daily and would have recommended hospitalization if they had known the resident required wound care more than once daily. For another resident with chronic respiratory failure, ventilator dependence, hypoxic ischemic encephalopathy, and facility-acquired stage 2 and 3 pressure ulcers, the wound care physician assistant documented an order for Silvadene to a right buttock ulcer. On the same date, the wound care nurse documented that the wound care physician assistant had evaluated the resident and changed the treatment to Santyl ointment, and then transcribed a physician order reflecting Santyl instead of Silvadene. This change in treatment product was not supported by the wound care physician assistant’s written order. The assistant director of nursing, who oversaw the wound care program, reported they could not recall the last time the wound care nurse had a wound care competency and stated that residents with pressure ulcers were being treated more than once daily because dressings became soiled with incontinence, while also acknowledging that treatments should follow wound care specialist recommendations and be provided more than once daily only as needed.
Inadequate Infection Control During Wound Care Leading to Cross-Contamination Risk
Penalty
Summary
The deficiency involves a failure to maintain infection prevention and control standards during wound care for a ventilator‑dependent resident with multiple pressure ulcers, including an infected right buttock ulcer on contact precautions. The resident had chronic respiratory failure with ventilator dependence, cerebral infarction, severe cognitive impairment, and was totally dependent on staff for activities of daily living. Physician orders documented contact precautions for the infected right buttock wound and specific topical treatments for multiple wounds on the buttocks, sacrum, mid‑back, and left lateral leg. The wound care nurse acknowledged that the right buttock wound had purulent discharge and showed signs of infection, making infection control important to prevent the resident’s other wounds from becoming infected. During an observed wound care procedure, the resident was positioned on their left side while a CNA assisted with positioning and the wound care nurse removed dressings from the right lateral and medial buttock, mid‑back, and sacrum. A towel under the resident became soaked with dark red drainage from the soiled dressings, and no barrier or drop cloth was placed between the resident’s open wounds and the towel. When the wound care nurse stepped away to change gloves and obtain more supplies, the CNA allowed the resident to drop slightly onto their back, causing the sacral and buttock wounds to come into direct contact with the towel saturated with drainage. The wound care nurse later stated that a drop cloth barrier should have been used but was forgotten, and the Assistant DON, who also had infection control responsibilities, reported they had not observed the wound care nurse’s treatment practices, despite the expectation that residents with open wounds be provided with barriers to prevent contact with potentially soiled objects.
Failure to Prevent Bed Fall Due to Improper Turning Technique
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for bed mobility and had multiple comorbidities including cerebrovascular disease and severe cognitive impairment, sustained a fall from bed resulting in a head injury. The facility's fall prevention policy required individualized care planning and proper technique for turning and positioning residents in bed, including turning residents toward the caregiver and maintaining close proximity during movement. Despite these protocols, the resident was turned away from the Certified Nurse Aide (CNA) during in-bed care, and the CNA was not positioned on the side to which the resident was being turned. During the incident, the CNA turned the resident to the right side, away from themselves, while changing the resident's diaper and chux. The CNA then reached for clean linen placed at the foot of the bed, during which time the resident unexpectedly rolled and fell off the bed. The CNA attempted to prevent the fall but was unsuccessful. There were no side rails or grab bars on the bed, and the CNA did not call for additional assistance when turning the resident away from themselves, contrary to facility policy and supervisor instruction. Following the fall, the resident was found on the floor with a laceration and hematoma on the forehead, bruising on the hand, and an abrasion on the knee. The resident was alert and oriented, but due to the head injury, was transferred to the hospital where imaging revealed a subarachnoid hemorrhage and subdural hematoma. Interviews with staff confirmed that the CNA did not follow proper turning technique and did not seek help when required, directly contributing to the accident hazard and resulting injury.
Failure to Prevent Pressure Ulcer Development and Deterioration
Penalty
Summary
The facility failed to provide adequate care to prevent the development and deterioration of pressure ulcers for a resident identified as high risk. Resident #24, who had a history of pressure injuries and was assessed as high risk for pressure ulcers, was found to have redness on the left heel on 08/24/2024. Despite this, the resident's care plan was not promptly updated with necessary interventions to prevent further deterioration. The facility's policy required actions such as updating the care plan, implementing nursing interventions, and ensuring proper positioning and incontinence care, but these were not adequately followed. Observations and interviews revealed that the resident's heels were not off-loaded or elevated, and the resident was not repositioned every two hours as required. The resident was frequently observed with their heels resting directly on the footrest of a geriatric chair, and there was no documented evidence of turning and positioning between 8:00 AM and 8:00 PM. The facility staff, including Registered Nurse #26 and Certified Nursing Assistant #28, failed to implement or report necessary interventions, and there was a lack of communication and documentation regarding the resident's condition and care. By 08/29/2024, the resident's left heel had progressed to an unstageable ulcer with necrosis, indicating a significant decline in skin integrity. The facility's failure to implement timely and appropriate interventions, such as off-loading, turning, and repositioning, contributed to the deterioration of the resident's condition. Interviews with facility staff, including the Director of Nursing and the Medical Director, highlighted a lack of awareness and adherence to the facility's pressure ulcer prevention protocols, resulting in actual harm to the resident.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was consistently provided to meet the needs of residents on all shifts, as observed during a recertification survey. Multiple residents reported during interviews and a Resident Council Group meeting that the facility was short-staffed at times, leading to delays in call bell responses and residents not being able to get out of bed when desired. Specific instances included a resident waiting two hours for bathroom assistance and missing therapy sessions due to delayed assistance. Another resident reported being left in bed all day due to staffing shortages, particularly on weekends. The facility's staffing sheets from 7/25/24 to 8/25/24 revealed that the facility was understaffed on 19 out of 31 days, with direct care nursing staff below the minimum levels documented in the Facility Assessment. Interviews with staff members, including Certified Nurse Aides and the Staffing Coordinator, confirmed the use of double shifts and staffing agencies to cover regular staff absences. Despite these measures, staff reported challenges in providing timely care, with some aides working double shifts multiple times per week. The Director of Nursing claimed adequate staffing, supplemented by non-direct care helpers, but the deficiency in direct care staffing was evident.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received performance reviews at least once every 12 months, as required. During the recertification survey conducted from August 26 to August 30, 2024, it was found that eight randomly selected CNAs did not have documented performance reviews within the past year. These CNAs had been employed at the facility for over a year, with hire dates ranging from 2002 to 2021. Interviews with staff revealed that the Registered Nurse Unit Supervisor responsible for the 3-11 shift and the Staffing Coordinator, who was tasked with tracking the evaluations, could not provide an explanation for the oversight. The lack of performance evaluations was confirmed through staff interviews and a review of facility records.
Failure to Notify Resident's Representative of Health Status Change
Penalty
Summary
The facility failed to promptly notify a resident's representative of a significant change in the resident's health status. Specifically, the designated representative of a resident with diagnoses including pneumonia, chronic respiratory failure, and dementia was not informed when the resident developed pneumonia and was started on an antibiotic treatment. The resident's Quarterly Minimum Data Set indicated severely impaired cognition and complete dependence on staff for daily activities, underscoring the importance of family notification. The facility's policy required prompt notification of the resident's representative in the event of a change in condition. However, there was no documented evidence that the representative was informed about the pneumonia diagnosis and the initiation of Cefuroxime treatment. Interviews with the Director of Nursing and a Registered Nurse revealed that it was the nurses' responsibility to notify families, and the expectation was that families would be promptly informed of any changes, especially given the resident's dementia diagnosis. Despite this expectation, the notification did not occur in this instance.
Failure to Update Care Plan for Pressure Injury
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner to reflect the resident's changing needs and current status. Specifically, Resident #24, who had diagnoses including type 2 diabetes, Alzheimer's disease, and a history of pressure injuries, acquired a pressure injury on the left heel. Despite the resident's high risk for pressure ulcers, as indicated by a Braden Scale score of 11, the care plan was not updated with goals and interventions to promote wound healing. Observations and records revealed that Resident #24's care plan did not include interventions for the left heel redness and to prevent further deterioration of the heel's skin integrity. The resident was frequently observed with their heels resting directly on the footrest of a geriatric chair, without off-loading or elevation, and was not turned or repositioned during extended periods. The family member of Resident #24 reported noticing the heel redness and requested staff intervention, but was not aware of any measures being implemented except for a wound consult scheduled for a later date. Interviews with staff, including a Registered Nurse and Nurse Practitioner, confirmed that the left heel wound had progressed to an unstageable state. The staff acknowledged that preventative measures such as heel off-loading, turning, repositioning, and the use of heel boots should have been implemented immediately upon noticing the heel redness. The Director of Nursing and Medical Director also stated that interventions should have been initiated promptly based on nursing judgment and orders, including off-loading, turning, repositioning, and the use of supportive devices.
Failure to Implement Hand Roll Care Plans for Residents
Penalty
Summary
The facility failed to ensure that residents with limited range of motion and mobility received the necessary care and equipment to maintain or improve their function. Three residents, all with severe cognitive impairments and dependent on staff for daily activities, were care planned to use hand rolls to prevent contractures and maintain skin integrity. However, observations revealed that these residents were frequently without their prescribed hand rolls, indicating a lapse in the implementation of their care plans. For Resident #24, the care plan included bilateral Posey hand rolls, but observations over several days showed the resident without them. Interviews with staff revealed a lack of awareness and communication regarding the hand rolls, with no order placed in the electronic medical record. The family member expressed concerns about the resident's clenched hands and lack of hand rolls, which they had never seen in use. Resident #54 had a physician order for bilateral Posey hand rolls, but observations showed the resident without them, and the Treatment Administration Record lacked documentation of their use. Staff interviews indicated that the resident had refused the hand rolls, but this was not communicated to the nursing staff or documented. Similarly, Resident #91 was observed without the prescribed right hand roll, and staff interviews confirmed that the responsibility for ensuring the use of the hand roll was not adequately managed by the nursing staff.
Failure to Follow Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received necessary respiratory care in accordance with the physician's orders. Resident #308, who had diagnoses including chronic respiratory failure with hypoxia, shortness of breath, and pneumonia, was observed receiving oxygen therapy at a higher flow rate than prescribed. The physician's order dated 8/21/24 specified continuous oxygen at 2-3 liters per minute via nasal canula, but observations on 8/26/24 and 8/27/24 revealed that the resident was receiving 4 to 4.5 liters per minute. The Treatment Administration Records from 8/20/24 to 8/27/24 indicated that staff documented the administration of oxygen at the prescribed rate of 2-3 liters per minute every shift. However, during an observation on 8/27/24, a registered nurse adjusted the oxygen concentrator from 4.5 liters to 2 liters per minute after reviewing the order and acknowledging the discrepancy. The nurse was unable to explain why the order was not being followed, indicating a lapse in adherence to the prescribed respiratory care plan.
Deficiencies in Food Storage and Ice Machine Cleanliness
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the survey, expired peanut butter and jelly sandwiches were found in the walk-in refrigerator and on prepared lunch trays. Additionally, expired egg salad sandwiches were also observed on the trays. The Assistant Food Service Director acknowledged that the lunch meal trays were prepared the day before and suggested that staff mistakenly left the expired sandwiches on the truck. The Director of Food Service was unaware of why the expired sandwiches were present but emphasized the importance of adhering to use-by dates for infection control and illness prevention. Furthermore, the facility did not adhere to its policy regarding the storage of residents' personal food. Food items in the resident pantry refrigerator were observed beyond the three-day limit, and an undated ice cream cake was found in the freezer. A Licensed Practical Nurse stated that the refrigerator should be checked daily by Certified Nursing Assistants, but this had not been done for some time. Additionally, the first-floor resident ice machine was found to be unclean, with black slime observed inside the machine. The Director of Housekeeping stated that the Housekeeping Department was responsible for cleaning the ice machines and was unaware of the issue, although the last cleaning was documented. They acknowledged the importance of keeping the ice machines clean to prevent contamination.
Inadequate Infection Control and Prevention Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies identified during a recertification survey. The infection surveillance plan was not properly implemented, with no documentation available for infection onset dates, signs and symptoms, lab tests/results, isolation, and outbreak potential for July and August 2024. The Infection Preventionist admitted to not tracking infections in real-time, which hindered the identification and prevention of infection patterns. Additionally, the Water Management Plan for Legionella had not been reviewed or updated since December 2016, despite the Director of Maintenance acknowledging the requirement for annual reviews. Furthermore, the facility did not ensure that staff members were educated about the risks and benefits of the pneumonia vaccination, nor was there documentation of the vaccine being offered or declined. The Infection Preventionist admitted to not routinely offering the vaccine, and the Director of Nursing expressed concern over the disorganization in vaccine tracking. Enhanced Barrier Precautions were not properly implemented for four residents, as observed by the absence of doffing pails and supply carts outside their rooms, which the Infection Preventionist acknowledged should have been in place.
Failure to Document Pneumococcal Vaccine Offer and Education
Penalty
Summary
The facility failed to ensure that each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations. This deficiency was identified during a recertification survey, where it was found that there was no documented evidence that a resident with diagnoses of respiratory failure, seizures, and who was ventilator dependent, was offered, declined, or educated on the pneumococcal immunization. The facility's policy required that all new admissions be assessed for the need for the vaccine and that education be documented, but this was not followed for the resident in question. Interviews with the Infection Preventionist and the Director of Nursing revealed a lack of organization and accountability in tracking vaccine information. The Infection Preventionist admitted to not having a tool to track resident information and vaccine status, and there was no record of declinations from residents or their representatives. The Director of Nursing acknowledged the disorganization and the need for better tracking of vaccine status, indicating a systemic issue in the facility's vaccination program management.
Deficiency in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to ensure that all residents and staff were properly screened, educated, and offered the COVID-19 vaccine, as evidenced by the lack of documented immunization records for one resident and one staff member. Specifically, Resident #91, who had diagnoses of respiratory failure, seizures, and was ventilator-dependent, did not have documented evidence of receiving education, being offered the vaccine, or declining it. Additionally, there was no documentation of the COVID-19 vaccination status for Staff #37. Interviews with facility staff revealed systemic issues in maintaining and tracking vaccination records. The Infection Preventionist admitted to not having records of staff or residents who were offered, declined, or were educated on COVID vaccines, and did not follow up with staff who had not provided their vaccine history. The Registered Nurse Supervisor indicated that vaccine information for new admissions was passed down to the next supervisor without a proper tracking system. Furthermore, a Respiratory Therapist and two Certified Nurses Aides reported not being approached about their vaccine status or offered booster vaccines during their time at the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Yonkers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elizabeth Seton Children's Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Andrus On Hudson | 1 mi | ★★★★★ | 0 | 0 |
| Sans Souci Rehabilitation And Nursing Center | 1.9 mi | ★★★★★ | 3 | 0 |
| Hudson Hill Center For Rehabilitation & Nursing | 2.3 mi | ★★★★★ | 9 | 0 |
| St Cabrini Nursing Home | 2.6 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.