Hudson Pointe at Riverdale Center for Nursing and

Based on record review and staff interview, conducted during the abbreviated survey (#2651294) the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for one (1) of four (4) residents (Resident #1) sampled. Specifically, on 10/12/2025 Resident #1 had an unwitnessed fall out of bed and sustained discoloration of the left eye which the facility did not report. The findings are: The facility policy titled 'Abuse' last reviewed on 03/11/2024 documented it is the policy of facility that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of funds. The policy also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the Recertification survey from 07/21/2024 to 07/26/2024, the facility did not ensure that it promoted and facilitated resident self-determination by supporting resident choice. Specifically, residents' bathing preferences were not honored. This was evident for 2 of the 4 residents reviewed for Choices out of 38 sampled residents. (Resident #88, and #46). The findings are: The facility policy and procedures titled ADL-Shower with the last revised date February 2024 documented that it is the policy of the facility to shower residents, to cleanse, and refresh resident, observe the skin and to provide increased circulation. Place resident in a shower chair and drape with a bath blanket or other form of cover. 1. Resident #88 was admitted to the facility with diagnoses that included Peripheral Vascular Diseases and Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #88 as cognitively intact and dependent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews conducted during the Recertification survey, the facility did not ensure that Minimum Data Set (MDS) 3.0 assessments accurately reflected the residents' status. Specifically, the most recent Minimum Data Set (MDS) 3.0 assessments did not reflect that wander/elopement alarms were used for 2 residents. This was evident for 2 of 2 residents reviewed for Elopement Risk out of a sample of 38 residents. (Resident # 103 and #135). The findings are: 1.) Resident #103 was admitted to the facility with diagnoses which include Dementia, Depression, and Psychotic Disorder. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had impaired cognition and was dependent in performing activities of daily living. Also documented in the Section P0200-Alarm that Wander/Elopement Alarm was not used. On 07/22/24 at 12:15 PM Resident #103 was observed with a wander guard device on the right wrist. Elopement Risk assessment dated [DATE] documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review conducted during a recertification survey (EUC311), the facility did not ensure that a resident's care plan for falls was reviewed and revised. Specifically, staff did not complete a timely review and/or revision for the care plan for a resident who had an identified history of falls with injury. This was evident in 1 of 31 residents reviewed for care plans (Resident #52). The findings are: The facility's policy and procedure entitled Care Plan, Comprehensive, last updated 02/2024, states that the interdisciplinary team reviews and updates the care plans at least quarterly in conjunction with the required Minimum Data Set assessment. Resident #52 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Depression, Chronic Kidney Disease and Diabetes. The Minimum Data Set (a resident assessment tool) dated 06/03/2024 documented that the resident's cognition was severely impaired, that they wandered daily and used a Wanderguard to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review during the extended recertification and abbreviated (NY00290309) survey from 6/27/2022 to 7/12/2022, the facility did not ensure appropriate alternatives to bed/SR (SR) were implemented and that residents were adequately assessed prior to bed/side rails (SR) use. This was evident in 14 (Resident #s 85, 95, 42, 190, 23, 69, 76, 121, 63, 136, 71, 12, 40 and 31) of 14 reviewed for SR out of a sample of 43 residents. Specifically, Resident #s 85, 95, 42, 190, 23, 69, 76, 121, 63, 136, 71, 12, 40 and 31 were observed with SR in use without assessments that included risk of entrapment and ensure the bed's dimensions are appropriate for resident's size and weight prior to SR installation. The findings include, but are not limited to: The policy titled Proper Use of SR dated 6/2016 and last reviewed 12/2021 documented: the purposes of these guidelines are to ensure the safe use of SR as resident mobility aids and to prohibit the use of SR as restraints unless…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review during the recertification survey from 06/27/2022 and 7/12/2022, the facility did not ensure a resident received notification prior to changes in coverage for services covered by Medicare. This was evident for 1 (Resident #90) of 4 resident reviewed for Beneficiary Protection Notice. Specifically, the facility did not provide Resident #90 with a Notice to Medicare Provider Non-coverage (NOMNOC) explaining their right to an expedited review prior to the termination of their Medicare coverage. The findings are: The facility policy titled Skilled Nursing Facility (SNF) Beneficiary Notices Process last reviewed 1/22 documented residents are provided appropriate Medicare SNF notices informing them of their responsibilities for payments and rights to request appeal, Medicare billing or redetermination of coverage from the appropriate agency. Resident #90 had diagnoses of type 2 diabetes mellitus and atherosclerotic heart disease. A Minimum Data Set 3.0 (MDS) assessment dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the recertification survey from 6/27/2022 to 7/12/2022, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were transmitted timely. This was evident for 1 (Resident #1) of 2 residents reviewed for Resident Assessment. Specifically, the facility did not transmit a Discharge MDS for Resident #1 within 14 days. The findings are: The facility's policy titled Resident Assessment last reviewed 2/2022 documented the MDS Coordinator (MDSC) is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments and reviews. Discharge assessments are conducted when a resident is discharged from the facility. Resident #1 was admitted on [DATE] with diagnoses of dementia and hypertension. Resident #1 was discharged from the facility on 1/26/2022. A Discharge MDS initiated and completed on 1/26/2022 documented Resident #1's return to the facility was not anticipated. As of 6/29/2022, the Discharge MDS did not have a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews conducted during the recertification survey, the Facility did not ensure the Minimum Data Set (MDS) assessment accurately reflects the resident's status for 2 (Resident # 90 and Resident # 108) of 2 residents reviewed for Resident Assessment out of an investigative sample of 42 residents. Specifically, 1) Resident #108's most recent MDS assessment inaccurately documented Resident #108 received dialysis; 2) Resident #90's most recent MDS assessment inaccurately documented Resident #90 had adequate hearing. The findings are: The findings are: The facility's policy titled Resident Assessment last revised 02/2022 documented the MDS Coordinator (MDSC) is responsible for ensuring appropriate resident assessment and reviews. 1) Resident # 108 was had diagnoses of hypertension, cerebral vascular accident, and seizures. The MDS dated [DATE] did not document Resident #108 documented the Resident #108 was receiving dialysis treatment. There was no documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and staff interviews conducted during the recertification survey, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 4 (Residents #55, 120, 37 & 77) of 12 residents on 1 (3rd floor) of 4 units observed during the Medication Administration Facility Task. Specifically, a Licensed Practical Nurse (LPN #5) was observed using a glucometer machine for multiple residents without sanitizing the equipment in between the residents. The findings are: The facility's policy titled Administration of Medication, reviewed 03/02/22, documented in the section Obtaining a Fingerstick Glucose level, that staff should always ensure that blood glucose meters intended for reuse are cleaned with germicidal wipes and disinfected between resident uses. On 06/28/22 09:48 AM, Licensed Practical Nurse (LPN) #5 was observed checking residents' blood glucose on the 3rd floor. LPN #5 removed the glucometer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed and implemented. Specifically, a resident with a diagnosis of Diabetes Mellitus did not have a CCP developed for this condition. This was evident for 1 of 6 residents reviewed for Unnecessary Medications out of a sample size of 34 residents. (Resident #125) The findings are: The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #125 as cognitively intact, with a diagnosis of Diabetes Mellitus, and received insulin injections daily. The Physician's Orders renewed on 8/17/19 documented that Resident #125 received 7 units of Humalog KwikPen (U-100) Insulin subcutaneously 3 times daily before meals (hold if fingerstick blood sugar (FSBS) is less than 110) and 34 units of Lantus Solostar (U-100) Insulin subcutaneously once daily at 8 PM. The Medication Administration Record (MAR) for August 2019 documented that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, (1) infection control policies were not reviewed and revised annually; and, (2) a resident with a urinary catheter was observed with catheter tubing laying on the floor. (Resident #125) The findings are: 1. The facility Infection Control Policies and Procedures revised on 9/2016 documented that the Nursing department is responsible for reviewing all policies and procedures at least annually and revising them as necessary. The facility policy and procedure titled Influenza revised on 3/10/2017 did not document that employees will be required to wear a face mask during flu season if they declined to receive the flu vaccine. The facility policy and procedure titled Flu (Influenza) Vaccination: Residents documented a revision date of 10/8/2017. On 08/20/19 at 10:05 AM, an interview was conducted with the Assistant Director of Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.