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 River Ridge Living Center during CMS and state inspections, most recent first.
A resident’s chart contained repeated inaccurate NP documentation stating the resident had multiple pressure areas, despite later review and staff statements that the resident had no open wounds. The resident had significant neurologic and mobility-related diagnoses, and the facility’s records were not documented objectively and accurately as required.
Surveyors found that the facility did not maintain a pest-free environment in two private resident shower rooms and two main shower rooms, where dead and live ants and water bugs were observed on the floors. Housekeeping staff reported cleaning private showers every other day and notifying maintenance when pests were seen, but one aide acknowledged not cleaning a private shower because it was not used and they had only recently learned it existed. The Director of Maintenance described ants as an ongoing issue, stated that a pest control vendor provided monthly treatments, and reported that water in the two private showers was run weekly, while a maintenance staff member stated they ran water monthly and that it had last been run about six weeks earlier, relying on the Director of Maintenance to contact the pest control vendor when pests appeared.
The facility failed to uphold residents' dignity and care standards. A resident was given plastic utensils due to a shortage, another was left in distress without access to a call bell after dialysis, and a third did not consistently receive adaptive utensils. Staff on C Wing entered rooms without knocking, violating privacy. These actions compromised the quality of life for the residents.
A resident with end-stage renal disease, atrial fibrillation, and type 2 diabetes mellitus experienced issues with the facility's laundry process, resulting in missing personal clothing and a cell phone. The resident was unaware of the grievance process, and staff interviews revealed that resident laundry was often mishandled, leading to items not being returned. The facility's policy on personal property was not effectively implemented, contributing to the deficiency.
The facility did not ensure residents were aware of the grievance process, as grievance forms were not readily available, and residents could not file grievances anonymously. During a Resident Council meeting, residents reported they were unaware of the grievance process and did not know the Grievance Officer. Staff interviews revealed that grievance forms were not easily accessible, and there was no option for anonymous filing, indicating a lack of effective communication and training on the grievance policy.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident with respiratory issues did not consistently receive prescribed oxygen therapy. Another resident's abuse allegation was not investigated or documented, and no care plan was implemented to address potential abuse. A third resident requiring dialysis lacked a care plan for managing their condition. These oversights highlight significant gaps in care management.
The facility failed to update the care plans for two residents, leading to deficiencies in care. One resident's care plan for respiratory therapy was not revised despite their refusal to use a C-pap machine, and another resident's care plan for musculoskeletal disorder was not updated after they consistently removed a positioning wedge. Staff interviews revealed a lack of awareness and communication regarding these issues, resulting in a failure to provide appropriate care.
The facility failed to prevent an elopement and improperly stored medication. A resident with dementia eloped due to inadequate door security and response to alarms. Another resident had discontinued medication left accessible in their room, contrary to policy. Staff did not follow procedures for alarm response and medication storage.
The facility failed to provide continuous oxygen therapy as ordered for several residents with respiratory conditions. One resident was observed without oxygen due to inadequate equipment setup, another received oxygen at a lower rate than prescribed, and a third was found without their oxygen supply in a common area. Staff interviews revealed inconsistencies in monitoring and ensuring proper oxygen administration.
The facility failed to maintain adequate staffing levels, resulting in delayed care for residents. Observations and interviews revealed that staffing levels were often below the required minimum, leading to long wait times for assistance. Residents and staff reported frequent short-staffing, with staff having to perform additional duties and work extra hours. The administration acknowledged the staffing challenges and efforts to recruit and retain staff, but these were not always sufficient to meet residents' needs.
The facility's policy for drug regimen reviews lacked specific time frames for notifying the facility and physician of irregularities, as well as for physician response and nursing intervention. The DON was unaware of these deficiencies in the policy provided by the pharmacy.
A facility's medication error rate exceeded 5% due to improper administration by staff. One resident's medication was given to a family member to administer without supervision, and another resident received insulin without proper priming of the pen. Staff interviews confirmed these actions were against facility policy.
The facility failed to properly label and store medications, with insulin pens, vials, inhalers, and eye drops lacking open or expiration dates. A Novolog Kwik insulin pen was incorrectly stored, and discontinued medications were not disposed of according to policy. Staff interviews revealed confusion about medication management responsibilities.
Two residents experienced issues with meal service, receiving cold and incorrect meals that did not match their dietary tickets. Staff shortages and lack of communication led to unappealing and unappetizing food, with residents not being informed of substitutions. Complaints about cold food were common, and staff failed to verify meal accuracy.
A resident with dementia and other conditions did not consistently receive adaptive eating utensils as required by their care plan. Observations showed the resident lacked a built-up fork, and staff interviews revealed a shortage of adaptive utensils in the kitchen, leading to the deficiency.
The facility failed to maintain food safety and sanitation standards in the main kitchen and two kitchenettes. Observations revealed soiled equipment and surfaces, improper sanitizing solution testing, and maintenance issues such as scraped walls and duct-taped freezer panels. The administrator acknowledged the deficiencies and planned to address them with relevant staff.
The facility did not ensure proper labeling of food brought by family or visitors for residents on the A-Wing Unit. During a survey, it was found that two restaurant entrees in the kitchenette refrigerators were not labeled with the resident's name, date received, and use-by date, as required by the facility's policy. This was confirmed by an administrator who acknowledged the oversight.
The facility failed to maintain an effective infection prevention and control program, with deficiencies observed in dressing changes for two residents and isolation precautions for COVID-19 positive residents. LPNs did not adhere to proper hand hygiene and glove-changing protocols, leading to potential wound contamination. Additionally, isolation room doors were left open, and a water system assessment for Legionella was not completed.
A fly infestation was observed in a resident unit, with flies found in corridors and around a resident with a feeding tube. Staff and family members reported ongoing issues despite pest control efforts. The Administrator acknowledged the problem and noted recent pest control treatment.
A resident with chronic health conditions was observed self-administering nebulized medication without an assessment or physician's order, contrary to facility policy. Despite being cognitively intact, the resident had not been evaluated for their ability to safely self-administer medication, and nursing staff routinely allowed this practice without the required interdisciplinary assessment.
Two residents in an LTC facility were not given the opportunity to make choices about their care, leading to deficiencies. One resident, with sleep apnea, was not allowed to choose when to use their C-PAP machine, while another, returning from dialysis, was left waiting to be put to bed despite expressing exhaustion. Both cases showed a lack of communication and documentation of resident preferences, resulting in unmet needs and dissatisfaction.
A resident with severe cognitive impairment fell and sustained injuries due to neglect in a facility. A CNA, unfamiliar with the care plan, provided care alone instead of the required two-person assist, and floor mats were not in place as planned. This resulted in the resident rolling out of bed and suffering facial bruising and a laceration.
The facility failed to report allegations of abuse involving two residents within the required timeframe. One resident fell out of bed due to a CNA not following the care plan, and the incident was reported two days late. Another resident reported rough handling by an agency nurse, resulting in facial marks, but the incident was not reported to the state. The facility's policy requires immediate reporting of such incidents, which was not followed.
The facility failed to monitor the nutritional status and conduct necessary assessments for two residents, leading to unaddressed weight changes and lack of comprehensive care plans. One resident experienced significant weight loss without proper monitoring or dietary assessment, while another lacked a nutrition care plan and had outdated assessments. The transition to a new RD contributed to these oversights.
A resident with multiple medical conditions reported that an agency nurse was rough when applying a C-Pap mask, resulting in facial marks. The incident was communicated to a CNA, an LPN, and administration, but no investigation or required reporting to the Department of Health was conducted. The DON and administrator were aware of the allegation but did not document, investigate, or take further action, and the incident was only discovered during a survey review.
Inaccurate Documentation of Resident Skin Condition
Penalty
Summary
The facility failed to maintain accurate documentation in accordance with accepted professional standards for one resident. Nurse Practitioner #1 documented that the resident had multiple pressure areas during four encounters, but the record and interviews indicated this documentation was incorrect. The facility policy required documentation to be objective, complete, and accurate, and to reflect all services provided and changes in the resident’s condition. Resident #1 was admitted with diagnoses including acquired absence of a leg above the knee, spastic hemiplegia affecting the nondominant side, muscle weakness, and dysphagia. The resident’s MDS indicated the resident could usually understand others and had intact cognition for daily living decisions. Progress notes on multiple dates documented the skin as warm and dry with multiple pressure areas, yet later interview statements from the DON and Nurse Practitioner indicated the resident had no open wounds and that the pressure-area documentation was incorrect.
Failure to Maintain Pest-Free Conditions in Resident and Main Shower Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain a pest-free environment and an effective pest control program in multiple shower areas, including two private resident shower rooms and two main shower rooms. During observations on 3/17/2026, dead and live insects, including ants and water bugs, were found in the private shower room of one resident room, and dead ants were found on the floor of another resident room’s private shower. Additional observations the same day revealed little black ants crawling on the floors of the Unit A and Unit C main shower rooms located across from specified resident rooms. These findings showed the presence of pests in resident shower areas that should have been maintained free of infestation. Interviews with staff revealed gaps in cleaning and maintenance practices related to these shower rooms. Housekeeping staff reported that private showers were cleaned every other day and that they notified maintenance when pests were seen, but one housekeeping aide stated they had been employed for about three months and only learned of one private shower a week prior, and had not cleaned it because it was not used. The Director of Maintenance stated that ants had been an ongoing problem attributed to residents dropping food, and that a pest control vendor provided monthly treatments, including a visit on the morning of 3/17/2025. The Director of Maintenance also stated that water in the two private showers was run weekly, while a maintenance staff member reported that they ran water in those showers monthly and that the last time water was run was about a month and a half earlier. Maintenance staff also indicated they relied on the Director of Maintenance to contact the pest control vendor when pests were observed, as they were not permitted to use spraying chemicals themselves.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect, dignity, and care in a manner that promotes their quality of life. Resident #19 was provided with plastic utensils for their meal due to a shortage of silverware, which was acknowledged by the Kitchen Supervisor. The supervisor mentioned that the facility had run out of spoons and was unsure when new ones would arrive, leading to residents not receiving proper utensils for their meals. Resident #34, who was cognitively intact and required assistance for activities of daily living, was left in their wheelchair without access to a call bell after returning from an early morning dialysis appointment. The resident expressed distress and helplessness as they were unable to reach the call bell to request assistance to return to bed. Despite being aware of the resident's needs, staff failed to provide timely assistance, leaving the resident in discomfort for over an hour. Resident #38, who required adaptive utensils for meals, was not consistently provided with the necessary equipment. Observations revealed that the resident sometimes received the adaptive utensils and sometimes did not, depending on the kitchen's inventory. Additionally, staff on C Wing were observed entering residents' rooms without knocking, violating residents' rights to privacy and dignity. This behavior was noted among both nursing and housekeeping staff, indicating a systemic issue within the facility.
Failure to Maintain Resident's Personal Belongings
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for a resident, as evidenced by the mishandling of the resident's personal clothing and belongings. The resident, who was admitted with end-stage renal disease, atrial fibrillation, and type 2 diabetes mellitus, reported that their personal clothing was not laundered and returned in a timely manner. Specifically, the resident stated that they originally had 15 pairs of pants, but only 3 pairs were returned after laundry. Additionally, the resident reported a missing cell phone, which had not been found or returned. The resident was not informed about the grievance process and was unaware that they could file a grievance regarding their missing items. Interviews with facility staff revealed that the facility's laundry process involved sending linens to an outside company, and there was a system in place to differentiate between resident clothing and linens. However, staff often placed resident laundry in the wrong bags, resulting in items being sent out and sometimes not returned. The Director of Nursing acknowledged the issue and stated that the facility was attempting to move all laundry in-house. The Social Worker was unaware of the resident's missing items and stated that grievance forms were available, but the resident's complaint had not been brought to their attention. The facility's policy on personal property emphasized respect for resident belongings, but the inventory of personal items was not documented upon the resident's admission, contributing to the deficiency in maintaining a homelike environment.
Deficiency in Resident Grievance Process Awareness
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process, as evidenced by the lack of readily available grievance forms and the inability for residents to file grievances anonymously. During a Resident Council meeting, all seven residents present reported they were unaware of the grievance filing process and did not know who the Grievance Officer was. Instead, residents typically brought their concerns to the Unit Manager, but felt these concerns were not always addressed. The facility's policy required quarterly education on the grievance process, but this was not effectively communicated to the residents. Interviews with facility staff revealed further issues with the grievance process. The Director of Social Work, who served as the Grievance Officer, acknowledged that grievance forms were not easily accessible to residents and that there was no option for anonymous filing. Although forms were kept in specific locations, residents had to request them, which posed a barrier. The Director of Nursing also confirmed the lack of an anonymous filing option and was unaware of the grievance process details, indicating a lack of staff training and communication regarding the grievance policy.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. Resident #24, who was diagnosed with chronic obstructive pulmonary disease, emphysema, and acute respiratory failure with hypoxia, was not consistently provided with the prescribed continuous oxygen therapy. Observations revealed that the resident was often without supplemental oxygen, despite a physician's order for continuous oxygen delivery via nasal cannula. Interviews with staff indicated a lack of understanding and adherence to the oxygen therapy order, contributing to the deficiency. Resident #32, who had osteomyelitis, obstructive sleep apnea, and a wound infection, reported an allegation of abuse that was not investigated or documented by the facility. The resident experienced rough handling by a staff member while using a C-PAP machine, resulting in a red mark on their nose. Despite the resident's report and visible evidence of the incident, the facility failed to address the allegation, involve social work, or implement a care plan to protect the resident from potential abuse. Resident #73, diagnosed with end-stage renal disease requiring dialysis, dysphagia, and anemia, did not have a comprehensive care plan for dialysis management. The resident's care plan lacked goals and interventions related to dialysis, which is critical for managing their kidney disease and fluid balance. The absence of a structured care plan for dialysis was acknowledged by the nursing staff, highlighting a significant oversight in the resident's care management.
Failure to Update Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that Comprehensive Care Plans were reviewed and revised by the interdisciplinary team for two residents, leading to deficiencies in care. For Resident #32, the care plan for respiratory therapy was not updated to reflect the resident's refusal to use their C-pap machine for severe sleep apnea. Despite multiple refusals documented in the Treatment Administration Record, there was no evidence in the care plan of these refusals or any physician notification. Observations revealed that the resident was using oxygen via a nasal cannula without a corresponding order or regular monitoring of oxygen saturation levels. Interviews with staff indicated a lack of awareness regarding the broken C-pap mask and the resident's refusal to use it, highlighting a communication gap and failure to update the care plan accordingly. For Resident #68, the care plan for musculoskeletal disorder was not revised after the resident consistently removed a wedge intended for positioning between their thighs. Observations and interviews with staff revealed that the resident frequently removed the wedge or pillow, and alternative interventions had been trialed unsuccessfully. Despite these challenges, the care plan was not updated to reflect the resident's refusal or the ineffectiveness of the intervention. The Director of Rehabilitation acknowledged that the care plan should have been updated when the intervention was deemed inappropriate. The facility's policies require that care plans be revised when there are changes in a resident's condition or when interventions are no longer effective. However, in both cases, the care plans were not updated to reflect the residents' refusals or changes in their care needs. This oversight resulted in a failure to provide appropriate and individualized care, as required by the facility's policies and regulations.
Deficiencies in Supervision and Medication Storage
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent avoidable accidents for two residents. Resident #58, who was cognitively impaired and had a history of wandering, was able to elope from the facility. The door alarm near the C wing was activated, but the responding LPN did not see anyone near the door and turned off the alarm without conducting a head count. Resident #58 was later found in the parking lot by two nurses returning from their break. The facility's elopement policy was not followed, as the side doors did not have the required 15-second egress delay, allowing the resident to exit the building. Resident #74 had a container of triamcinolone acetonide cream stored on their nightstand, which was accessible to the resident and others entering the room. The cream was no longer prescribed for the resident, as the order had been discontinued. Despite this, the cream was left in the resident's room instead of being stored in the medication cart, as required by facility policy. Interviews with staff revealed that the resident was not assessed to self-administer medication, and the cream should have been removed from the room once it was no longer in use. The facility's policies on accidents and incidents, as well as wandering and elopement, were not adequately implemented, leading to these deficiencies. Staff interviews indicated a lack of adherence to procedures, such as conducting head counts after alarms and ensuring medications are stored securely. These oversights contributed to the unsafe conditions observed during the survey.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with professional standards for four residents who required oxygen administration. Resident #24, diagnosed with chronic obstructive pulmonary disease, emphysema, and acute respiratory failure with hypoxia, was observed without supplemental oxygen on multiple occasions, despite a physician's order for continuous oxygen via nasal cannula. The resident reported that the oxygen tubing did not reach the bathroom, and staff did not ensure the use of a portable oxygen tank attached to the wheelchair, leading to periods without oxygen. Resident #34, with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, was observed receiving oxygen at a lower rate than prescribed. The oxygen concentrator was set at 3.5 liters instead of the ordered 4 liters. The resident stated they were always on 4 liters of oxygen, but staff interviews revealed inconsistencies in monitoring and adjusting the oxygen levels, with some staff unaware of the correct settings. Resident #61, diagnosed with chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease, was found without their prescribed oxygen while in a common area. The resident indicated they were supposed to be on oxygen continuously but did not have an oxygen bottle in their wheelchair holder. Staff interviews confirmed the resident should have been on continuous oxygen, but there was a lack of clarity and follow-through in ensuring the resident had access to the necessary equipment.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple instances of staffing levels falling below the minimum requirements from January 1, 2025, to March 17, 2025. Observations and interviews revealed that the facility was consistently understaffed, particularly during day and evening shifts. The staffing schedule showed that on several occasions, the number of Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides on duty did not meet the facility's assessed minimum staffing levels. This shortage led to delays in responding to call bells and prolonged wait times for residents needing care. Interviews with residents, family members, and staff highlighted the impact of insufficient staffing on resident care. Residents reported being placed on the back burner and experiencing long waits for assistance. Staff members, including Certified Nurse Aides and Registered Nurses, confirmed the frequent short-staffing, which required them to perform additional duties and work beyond their scheduled hours. The facility's administration acknowledged the staffing challenges and their efforts to recruit and retain staff through bonuses and agency use, yet these measures were not always sufficient to meet the residents' needs. The Director of Nursing also recognized the persistent staffing issues, particularly on weekends, which resulted in residents waiting for care.
Lack of Time Frames in Drug Regimen Review Policy
Penalty
Summary
The facility failed to ensure the development of comprehensive policies and procedures for the monthly drug regimen review process. Specifically, the policy titled 'Long Term Care Solutions, Drug Regimen Review' lacked defined time frames for critical steps in the process. These steps include the notification of the facility and physician by the pharmacist upon identifying irregularities, the time allowed for the physician to respond to the report, and the time frame for nursing staff to address issues requiring intervention. The absence of these time frames in the policy indicates a gap in the facility's protocol for managing drug regimen reviews. During the recertification survey, it was noted that the policy did not specify the time frames for when the pharmacist should notify the facility and physician of any irregularities, nor did it outline how long the physician had to respond or how long the nursing staff had to address identified issues. The Director of Nursing acknowledged during an interview that the policy was provided by the pharmacy and was unaware of its deficiencies. This oversight in policy development could potentially impact the timely and effective management of residents' medication regimens.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.41% during a recertification survey. This deficiency was observed in two residents. The first resident, diagnosed with Alzheimer Disease, osteoarthritis, and constipation, was involved in an incident where an LPN allowed the resident's wife to administer Metamucil powder without supervision, contrary to facility policy. The LPN then inaccurately documented that the medication had been administered. Interviews with other nursing staff and the Director of Nursing confirmed that family members are not permitted to administer medications without a proper assessment and physician order. The second resident, with diagnoses including diabetes mellitus type 1, chronic kidney disease, and hypertension, was involved in an incident where an LPN failed to prime an insulin Kwik Pen before administering the prescribed dose of Humalog. The LPN was unaware of the requirement to prime the pen with each use, indicating a gap in knowledge despite the facility's training protocols. The Director of Nursing confirmed that all nurses receive training on medication administration, including insulin, and are observed by a preceptor before administering medications independently.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice. During the recertification survey, it was observed that medication carts in A, B, and C Wings, as well as a medication room in C Wing, contained insulin pens, vials, inhalers, and eye drops without open or expiration dates. Additionally, a Novolog Kwik insulin pen was incorrectly stored in a bag labeled for Degludec insulin, and two bottles of Megace liquid were found to be discontinued. Furthermore, an opened bottle of Jevity Tube feed and a black extra-large ice pack belonging to a discharged resident were improperly stored in the medication room refrigerator. The facility's policies and procedures require that all drugs and biologicals be stored safely and securely, with expiration dates checked prior to administration. Insulin pens should be clearly labeled with the resident's name, and discontinued medications should be returned to the pharmacy or destroyed. However, observations revealed that these protocols were not consistently followed. Interviews with staff, including an LPN and the Director of Nursing, indicated a lack of clarity regarding the collection and disposal of discontinued medications, as well as the responsibility for ensuring medication carts are clean and orderly.
Deficiency in Meal Service Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for two residents. During a resident council meeting, one resident complained that meals were consistently cold, unappealing, and often arrived with incorrect or missing items. An observation confirmed that the resident received a meal that did not match their lunch ticket, and the food temperatures were below the expected levels. The kitchen supervisor admitted to being short-staffed and not having the requested items, leading to the resident receiving a regular meal without being informed of the substitution. Another resident also experienced issues with meal service, receiving a tray that did not match their dietary ticket. The resident's meal was cold, and the food was not as ordered, leading to the resident consuming only a small portion of the meal. The resident expressed that the food was often inedible, prompting their family to bring food from outside. A certified nurse aide confirmed that cold food was a common complaint and that substitutions were made without informing the residents. Interviews with staff revealed a lack of communication and verification processes regarding meal substitutions and tray accuracy. The registered dietician acknowledged the need for residents to be informed of substitutions and expressed unfamiliarity with the resident's preferences. The facility administrator noted ongoing staff changes and common food complaints, emphasizing the need for staff to verify meal tickets and address issues with cold or disliked food promptly.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident with dementia, hypertension, and type 2 diabetes, who required adaptive devices to eat independently. The resident's care plan specified the need for a built-up fork, knife, and spoon with meals, as recommended by physical and occupational therapy. However, during observations, the resident was found without the necessary adaptive fork and sometimes received a regular curved spoon instead of the required built-up utensils. The resident confirmed that they occasionally did not receive the adaptive fork. Interviews with staff revealed that the kitchen sometimes lacked the necessary adaptive utensils, and the kitchen supervisor acknowledged the shortage and uncertainty about when new items would arrive. A Certified Nurse Aide confirmed that the resident was supposed to have built-up utensils, but availability depended on the kitchen's stock. A Registered Nurse stated that staff should verify meal trays for accuracy and contact the kitchen if items were missing, but this procedure was not followed, leading to the deficiency.
Food Safety and Sanitation Deficiencies in Kitchen and Kitchenettes
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 recertification survey, it was observed that the main kitchen and two of the three kitchenettes had several deficiencies. In the main kitchen, the test papers used to check the sanitizing solution did not have the correct graduation for measuring the quaternary ammonium compound, which is necessary to ensure the efficacy of the sanitizer. Additionally, various items such as bulk food containers, shelving, sheet pan racks, stoves, and the floor under cooking line equipment were found to be soiled with food particles. In the A-Wing and B-Wing kitchenettes, similar issues were noted. The microwave oven, refrigerator, and floors were soiled with food particles and dirt. The plastic panels in the freezer sections of the refrigerators were covered with white duct tape, and the walls were scraped with holes present. These observations indicate a lack of proper cleaning and maintenance in the food service areas, which could compromise food safety. During an interview, the administrator acknowledged these issues and mentioned plans to discuss them with the dietary, housekeeping, and maintenance staff.
Improper Labeling of Resident Food Brought by Family
Penalty
Summary
The facility failed to ensure that food brought for residents by family or visitors was stored safely and distinctly from facility food on the A-Wing Unit. During a recertification survey, it was observed that two restaurant entrees stored in the resident unit kitchenette refrigerators were not properly labeled with the resident's name, date received, and use-by date, as required by the facility's policy. This policy, documented in a document titled 'Food Brought by Family/Visitors' dated November 2024, mandates that all food brought to residents must be labeled accordingly. The deficiency was confirmed during an interview with Administrator #1, who acknowledged that the staff should have labeled the food and indicated that staff would be re-educated on this requirement.
Infection Control Deficiencies in Dressing Changes and Isolation Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a recertification and abbreviated survey. Specifically, the facility did not ensure proper infection control practices during dressing changes for two residents with pressure sores. For one resident, an LPN did not set up a clean field or perform proper hand hygiene during a dressing change, leading to contamination of the wound. The LPN failed to sanitize hands between glove changes and did not maintain a clean technique, which was acknowledged during an interview. Another resident experienced similar deficiencies during a dressing change performed by a different LPN. The LPN did not change gloves or sanitize hands after touching drainage and contents from inside the wound, leading to potential contamination. Despite recent training on infection control and dressing changes, the LPN did not adhere to the proper procedures, as confirmed by a registered nurse during an interview. Additionally, the facility did not maintain isolation precautions for residents who tested positive for COVID-19. Doors to isolation rooms were left open, contrary to droplet precaution protocols. Staff interviews revealed a lack of adherence to these precautions. Furthermore, the facility failed to complete a water system environmental assessment for Legionella within the past year, as confirmed by the facility administrator.
Fly Infestation in Resident Unit
Penalty
Summary
The facility failed to maintain a pest-free environment and an effective pest control program on one of its resident units, as evidenced by a small fly infestation. Observations on March 11, 2025, revealed little black flies in the corridors near several rooms and around a resident with a feeding tube on the C-Wing. The following day, flies were observed around staff serving meal trays. A family member reported that the infestation was severe enough to cover the television in a resident's room, noting that removing trash helped alleviate the issue. A Certified Nurse Aide mentioned that the black flying bugs had been present since their hiring, despite the facility having a pest control vendor. The Administrator acknowledged awareness of the fly problem and indicated that a pest control vendor had treated the issue the previous week.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that an interdisciplinary team assessed a resident's ability to safely self-administer medication when clinically appropriate. Specifically, a resident with chronic systolic congestive heart failure, chronic atrial fibrillation, and chronic obstructive pulmonary disease was observed self-administering nebulized medication in the solarium without having been assessed for their ability to do so safely. The facility's policy required that residents could only self-administer medications if the attending physician and the interdisciplinary care planning team determined they had the decision-making capacity to do so safely. The resident was cognitively intact and understood the self-administration process, as evidenced by their ability to articulate the frequency and method of their medication administration. However, a previous assessment indicated the resident expressed no interest in the self-medication program, and no further evaluation was conducted. Despite this, nursing staff routinely handed the resident their medication for self-administration without a formal assessment or physician's order, contrary to the facility's policy. Interviews with nursing staff and the Director of Nursing confirmed that the resident did not have the necessary assessment or order to self-administer their medication.
Failure to Respect Resident Choice in Care Planning
Penalty
Summary
The facility failed to ensure resident self-determination and choice for two residents, leading to deficiencies in care. Resident #32, who was cognitively intact and had a history of heart failure, obstructive sleep apnea, and osteomyelitis, was not given the choice of when to use their C-PAP machine. The resident expressed that the mask was often offered too early, interfering with their evening activities, and was not offered again if initially refused. Despite the resident's repeated requests for a more suitable schedule, the care plan did not reflect their preferences, and staff were unaware of the resident's concerns until the survey. Resident #34, diagnosed with end-stage renal disease, COPD, and anxiety, was not allowed to return to bed after early morning dialysis sessions, despite expressing exhaustion and pain. The resident was left in a wheelchair without access to a call bell and had to wait for assistance to return to bed. The care plan did not document the resident's preference to rest after dialysis, and staff were unaware of the resident's needs, leading to delays in care and the resident feeling upset and helpless. Both cases highlight a lack of communication and documentation regarding resident preferences, resulting in unmet needs and dissatisfaction. The facility's failure to incorporate resident choices into care plans and schedules contributed to the deficiencies observed during the survey.
Neglect Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a fall and injury. A Certified Nurse Aide (CNA) provided care to a resident who was care planned to require a two-person assist for bed mobility and transfers. During the care, the CNA turned the resident, causing them to roll out of bed and fall to the floor. This incident led to the resident sustaining ecchymosis to the right facial area and a laceration above the right eye. The resident involved had a history of vascular dementia, epilepsy, and major depressive disorder, with severe cognitive impairment. The care plan for the resident included the use of floor mats on both sides of the bed to prevent falls, which were not in place at the time of the incident. The CNA involved was from a staffing agency and was not familiar with the resident's care plan, leading to a break in protocol. Interviews with facility staff, including a Licensed Practical Nurse, a Registered Nurse, and the Director of Nursing, confirmed that the care plan was not followed. The CNA provided care alone, contrary to the requirement for a two-person assist, and the absence of floor mats further contributed to the resident's fall. The facility's failure to adhere to the care plan and ensure proper staffing and equipment placement resulted in the resident's injury.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents within the required timeframe. For Resident #14, an incident occurred where a Certified Nurse Aide did not follow the care plan, resulting in the resident falling out of bed and sustaining injuries. This incident was not reported to the New York State Department of Health until two days later, despite the requirement to report such incidents within two hours. The Director of Nursing and the Administrator were not made aware of the incident until two days after it occurred, leading to a delay in reporting. Resident #32 reported an incident where an agency nurse was rough while placing a C-pap mask, resulting in marks on the resident's face. The resident informed a Certified Nurse Aide and a Licensed Practical Nurse about the incident, but it was not reported to the New York State Department of Health. The Administrator and Director of Nursing were aware of the incident but did not report it, as they believed the resident had not been abused. There was no documentation to support their decision not to report the incident. The facility's policy requires all allegations of abuse, neglect, or exploitation to be reported immediately to the appropriate authorities. However, in both cases, the facility failed to adhere to this policy, resulting in a deficiency. The lack of timely reporting and investigation of these incidents highlights a failure in the facility's processes for handling allegations of abuse.
Failure to Monitor Nutritional Status and Conduct Assessments
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status and provide nutrition care and services consistent with the residents' comprehensive assessments for two residents. Resident #51, who was at risk for weight changes due to conditions such as Parkinson's Disease, lymphoma, and severe protein-calorie malnutrition, did not have their weight monitored as indicated in their care plan. The resident experienced significant weight loss, and a quarterly dietary assessment was not completed. Interviews revealed that the resident was a picky eater and often refused supplements, preferring a jelly sandwich instead. A scheduled interdisciplinary team meeting to address the resident's nutritional status was canceled due to a survey, and the transition to a new Registered Dietitian contributed to the oversight in completing the dietary assessment. Resident #64, diagnosed with chronic congestive heart failure, acute respiratory failure, and chronic kidney disease, also did not receive appropriate nutritional care. The resident's weight was not monitored as scheduled, and there was no comprehensive care plan regarding nutrition. The most recent nutrition assessment was from a year ago, and quarterly assessments were not conducted. Interviews indicated that the resident should have had a nutrition care plan, which was typically completed by the Registered Dietitian, but this was not in place. The facility's policy required nutritional assessments to be conducted upon admission, quarterly, and as needed based on changes in condition. However, these assessments were not completed for the residents in question, leading to a failure in recognizing, evaluating, and addressing their nutritional needs. The Director of Nursing acknowledged the oversight and attributed it to the transition to a new Registered Dietitian, who did not complete the necessary assessments despite repeated requests.
Failure to Investigate and Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was thoroughly investigated and reported in accordance with its own policy and regulatory requirements. The incident involved a resident with diagnoses including heart failure, obstructive sleep apnea, and osteomyelitis of the spine, who was cognitively intact and able to communicate. The resident reported that an agency nurse was rough when placing a C-Pap mask, causing the strap to hit their face and the mask to be applied too tightly, resulting in marks on the resident's face. The resident communicated this to a Certified Nurse Aide and later to an LPN, and the incident was also reported to administration. Despite the resident's report and visible marks, there was no documented evidence that the facility initiated an investigation or reported the incident to the Department of Health as required. The administrator and DON were both made aware of the allegation, but neither took steps to investigate, document, or report the incident. The DON acknowledged that an investigation should have been conducted and the accused staff member removed from resident care, but no such actions were taken. The agency nurse involved did not return to the facility, and the resident's family also raised concerns with a unit manager who was no longer employed at the facility. The facility's policy required immediate and thorough investigation of all abuse allegations, including documentation, staff interviews, and timely reporting to authorities. However, these procedures were not followed in this case, and the incident only came to light during a survey review, nearly two months after the alleged event. There was no documentation of any investigation, interviews, or findings related to the incident, and the required notifications to the Department of Health were not made within the mandated timeframe.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 76 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Amsterdam
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wilkinson Residential Health Care Facility | 3.4 mi | ★★★★★ | 0 | 0 |
| Capstone Center For Rehabilitation And Nursing | 5.3 mi | ★★★★★ | 0 | 0 |
| Wells Nursing Home Inc | 9.6 mi | ★★★★★ | 1 | 0 |
| Nathan Littauer Hospital Nursing Home | 11 mi | ★★★★★ | 0 | 0 |
| Fulton Center For Rehabilitation And Healthcare | 12.4 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.