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 View Rehabilitation And Nursing Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions was physically and verbally mistreated by a registered nurse supervisor during a transfer, resulting in pain, a visible neck injury, and emotional distress. Multiple staff witnessed the supervisor aggressively grabbing the resident's neck and responding inappropriately to the resident's pleas to stop. The incident led to the resident feeling unsafe and leaving the facility against medical advice.
The facility failed to follow planned menus, resulting in residents not receiving their preferred food items. Residents expressed dissatisfaction with missing meal items and lack of alternatives. Staff interviews revealed inconsistencies in meal preparation and distribution, with issues in matching meal tickets to residents' selections. Additionally, there was a lack of coordination in providing coffee, leading to residents not receiving their preferred beverages.
The facility failed to maintain food safety and hygiene standards, with unclean kitchen areas, improper food storage temperatures, and inadequate hand hygiene practices. Observations revealed dried brown rings and dead bugs in sinks, debris around kitchen equipment, and unsafe food temperatures in refrigerator #9. Staff did not follow hand hygiene protocols, leading to potential contamination risks.
A facility failed to ensure residents' privacy by installing monitoring devices in all rooms without obtaining consent. The devices transmitted personal health information to a third-party company, and residents were unaware of their presence and purpose. Staff and administration were unclear about the devices' functionality and consent process, and no documented consents were provided.
The facility failed to provide meals at appropriate temperatures, with residents reporting cold and unappetizing food. Observations showed meals served below required temperatures, contrary to facility policy. Staff interviews revealed a lack of documented test trays, and the Administrator acknowledged complaints about food quality.
A facility failed to ensure a Binding Arbitration Agreement was properly explained and completed for a resident with moderately impaired cognition. The agreement was sent via email to the resident's representative but was not completed correctly, lacking necessary acknowledgements and signatures. The Business Office Manager signed off on the resident's ability to make an informed decision, despite the resident having a health care proxy. The facility did not review the returned document for completeness, leading to the resident being added to the binding arbitration list without proper verification.
A facility failed to maintain a clean and safe environment, with debris found repeatedly in a resident's room and significant water damage in a medication room. Staff interviews revealed lapses in cleaning practices and concerns about potential mold. The Administrator was aware of the issues but deemed the water damage cosmetic.
The facility failed to make survey results readily accessible, placing them in a hard-to-reach location without proper signage. Residents and staff were unaware of the results' location, and the Administrator admitted to not replacing signage after remodeling.
Resident Physically and Verbally Abused During Transfer
Penalty
Summary
A deficiency occurred when a registered nurse supervisor physically and verbally mistreated a resident during a transfer. The resident, who had chronic obstructive pulmonary disease, vertigo, and was dependent on staff for transfers, was being assisted by staff using a sit-to-stand device. The resident became fearful and resisted the transfer, at which point the nurse supervisor placed their hand around the resident's neck, reportedly squeezing hard and causing pain. Multiple certified nurse aides witnessed the supervisor holding the resident by the neck in an aggressive manner, despite the resident's repeated requests to let go due to pain. The supervisor also raised their voice at the resident and responded to the resident's threat to hit them by stating they would hit the resident back. The incident resulted in a visible scratch and redness on the resident's neck, as documented by nursing staff and observed by police. The resident complained of neck pain and emotional distress, expressing a desire to call the police and have the supervisor arrested. Staff interviews consistently described the supervisor's actions as rough, aggressive, and excessive, with no indication that the resident was at risk of falling at the time the supervisor grabbed their neck. The resident and their spouse both reported ongoing fear and distress following the incident, with the resident ultimately choosing to leave the facility against medical advice due to feeling unsafe. The facility's internal investigation initially did not identify the supervisor's actions as abuse, citing a lack of intent to harm and conflicting staff perceptions during a reenactment. However, multiple staff statements and the resident's own account indicated that the supervisor's physical and verbal conduct caused actual harm and mental anguish to the resident. The incident was reported to the police, and the supervisor was suspended and subsequently resigned. The deficiency was cited for failure to protect the resident from abuse, resulting in actual harm.
Failure to Follow Planned Menus and Provide Preferred Food Items
Penalty
Summary
The facility failed to ensure that planned menus were followed for three residents, resulting in them not receiving their preferred food items as indicated on their individualized meal tickets. The facility's policy required the Food Service Manager to observe meals for preferences and accuracy, and to report any concerns to the appropriate staff. However, during the survey, it was observed that residents did not receive the meals they selected, and their trays were often missing food items. For instance, Resident #32 was supposed to receive Shepherd's pie and other specific items but instead received a different meal due to the kitchen running out of the main entree. The deficiency was further highlighted during interviews and observations. Residents expressed dissatisfaction during a Resident Council Meeting, stating they did not always receive the meals they selected and were not offered alternatives. Staff interviews revealed confusion and inconsistency in the meal preparation process. The Administrator was temporarily overseeing the kitchen due to the absence of a Director of Dietary, and there were issues with the production sheets and meal tickets not matching the residents' selections. This led to inaccuracies in meal preparation and distribution. Additionally, there was a lack of communication and coordination regarding the provision of coffee, which was supposed to be available on the unit but was not consistently offered to residents. Staff interviews indicated that coffee was not sent from the kitchen, and residents had to be on a specific list to receive it. This inconsistency contributed to residents not receiving their preferred beverages, as evidenced by Resident #581's complaint about not receiving coffee despite it being on their meal ticket.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations revealed multiple instances of unclean areas in the main kitchen, including dried brown rings and dead bugs in the dish room hand sink, tan sludge on the floor under the three-bay sink, and debris on the side of the oven and under the sink. Additionally, there was a wet, gray liquid beneath the three-bay sink due to improper drainage, and garbage overflowed onto the floor. The basement hall floor, used for staging trays for meal service, was soiled and stained, with meal carts left uncovered. The facility also failed to maintain proper food storage temperatures. During meal service, butter in refrigerator #9 was measured at temperatures significantly above the required 41 degrees Fahrenheit, with readings as high as 51 degrees Fahrenheit. Other items, such as mozzarella cheese and yogurt, were also found at unsafe temperatures. The facility lacked documentation on cooling times and temperatures for potentially hazardous foods like lasagna and eggs, which were stored in the rapid cooling refrigerator without proper logs. Staff were unsure of safe temperature requirements and failed to monitor and record refrigerator temperatures adequately. Furthermore, there was a lack of proper hand hygiene during meal service. Dietary aides and other staff members were observed leaving and re-entering the kitchen without changing gloves or performing hand hygiene, despite handling food and kitchen equipment. The facility's policies required hand washing upon entering the kitchen and after touching non-food items, but these were not followed. The Administrator acknowledged the absence of kitchen cleaning audits and the need for proper hand hygiene, emphasizing the importance of maintaining cleanliness and safe food storage temperatures.
Privacy Breach Due to Unconsented Monitoring Devices
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records for 50 out of 77 residents reviewed during a recertification survey. The deficiency was identified when it was discovered that individual monitoring devices were installed in all resident rooms, transmitting personal health information to a third-party company without obtaining consent from the residents or their representatives. The facility's Privacy Practices document stated the requirement to maintain the privacy of residents' health information, but this was not adhered to in practice. Observations and interviews revealed that residents were unaware of the presence and purpose of these monitoring devices. One resident with moderately impaired cognition did not know about the device above their bed, while another resident with intact cognition believed the device was a camera and was not informed about its actual function. Staff members, including a Certified Nurse Aide and a Licensed Practical Nurse Unit Manager, were also unclear about the devices' purpose and the consent process, with some believing the devices were installed due to Department of Health requirements. The facility's administration was unable to provide documented consents or declinations for the monitoring devices. The Administrator and Corporate Director of Facilities were uncertain about the devices' functionality, the nature of the reports received from the third-party company, and whether residents were being monitored. Despite the devices being installed for nine months, the facility had not established a clear process for obtaining consent or notifying families, and the devices were reportedly not operational due to system integration issues.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, flavorful, and at an appetizing temperature. During the recertification and abbreviated surveys, it was observed that meals served on two separate days were not at the appropriate temperatures. Specifically, the lunch meals on 11/13/2024 and 11/14/2024 were served cold, burnt, and not flavorful. Residents at a Resident Council meeting reported that the food was cold and unappetizing, with specific complaints about grilled cheese sandwiches being too hard and ice cream being melted. Additionally, Resident #2 reported that the food was bland and cold. Observations during meal times revealed that food items were not maintained at the required temperatures as per the facility's policy. For instance, a grilled cheese sandwich was served at 110.8 degrees Fahrenheit, and milk was served at temperatures ranging from 46 to 59.5 degrees Fahrenheit, which were below the acceptable standards. The facility's policy required hot foods to be served at 135 degrees Fahrenheit or above and cold foods at 41 degrees Fahrenheit or below. Interviews with staff indicated that there were no documented test trays, and the Administrator acknowledged receiving complaints about the food but stated it was challenging to please everyone.
Incomplete Binding Arbitration Agreement for a Resident
Penalty
Summary
The facility failed to ensure that the Binding Arbitration Agreement was properly explained and completed for Resident #63 during the recertification survey. The agreement, which was part of the admission packet, was sent via electronic mail to the resident's representative but was not completed correctly. The section for resident/representative acknowledgements was left incomplete, with no initials or signature indicating that the agreement, the ability to rescind, and the right to communicate with officials were explained. Despite this, the Business Office Manager signed off, indicating the resident was capable of making an informed decision, even though the resident had moderately impaired cognition and a health care proxy in place. Interviews revealed that the facility had been offering arbitration agreements for about six months, and the Business Office Manager included it as a voluntary option in the admission packet. However, they did not specifically ask residents to agree, relying instead on family members to assist in understanding. The Business Office Manager used a checklist to ensure understanding but did not know how to select an arbitrator or if the agreement could be presented in other languages. The agreement was not reviewed for completeness upon return, and the resident was added to the binding arbitration list without proper verification. The Administrator and Business Office Manager acknowledged the oversight, noting that the document signing website should not have marked the document as complete. They admitted that the facility should have reviewed and followed up on the incomplete agreement. The Administrator believed the representative understood the agreement because they accepted it on the form, but the Business Office Manager clarified that the agreement could only be rescinded within 30 days, despite the Administrator's belief that it could be rescinded at any time.
Environmental Deficiencies in Resident and Medication Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as observed during a recertification survey. In one resident room, debris such as a greeting card, a brown napkin, and a red beverage cap were repeatedly found under the bed over several days, despite the facility's housekeeping policy requiring daily cleaning. Interviews with staff and visitors revealed that the floors were often sticky, and debris was not promptly cleaned, posing a potential fall hazard. Housekeeping staff admitted to not noticing the debris under the bed, indicating a lapse in the cleaning process. Additionally, the second-floor medication room was found to have significant water damage to the ceiling, floors, and walls, with large areas of brown discoloration and debris. This damage was attributed to a roof leak that had been repaired over the summer. Despite the repairs, the water damage remained unaddressed, and staff expressed concerns about the potential presence of black mold. The Maintenance Director, who was newly hired, acknowledged the need for repairs but noted that no work order had been submitted. The Administrator was aware of the damage but considered it cosmetic rather than a safety concern.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the results of the most recent Federal and State survey were posted in a location that was readily accessible to individuals wishing to examine them. The survey results and plan of correction were placed above the front desk, making them difficult to access. Additionally, there was no signage in the front lobby or other prominent areas of the facility to inform residents and visitors of the location of the survey results. During a Resident Council Meeting, 11 anonymous residents expressed that they were unaware of the location of the survey results and their right to access them. Observations revealed that the binder labeled 'Annual Survey' was inconsistently placed and not easily accessible. It was initially found on a wall cabinet over 6 feet high and later moved to a cubby above the front desk, obscured by a table. Staff members, including a Certified Nurse Aide and a Receptionist, were unaware of the location or purpose of the binder. The Administrator acknowledged responsibility for the survey results but admitted that signage had been removed during remodeling and not replaced. Despite claims that the results were discussed at Resident Council meetings, there was no evidence of survey results or signage on the second floor, where some staff believed they might be located.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ideal Senior Living Center | 9.3 mi | ★★★★★ | 6 | 0 |
| Absolut Ctr For Nursing & Rehab Endicott L L C | 9.8 mi | ★★★★★ | 1 | 0 |
| Vestal Park Rehabilitation And Nursing Center | 11.7 mi | ★★★★★ | 0 | 0 |
| Good Shepherd Village At Endwell | 12.1 mi | ★★★★★ | 6 | 0 |
| Willow Point Rehabilitation And Nursing Center | 14.2 mi | ★★★★★ | 0 | 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.