AMSTERDAM, NY - Federal inspectors documented widespread safety violations at River Ridge Living Center during a March 2025 inspection, citing the facility for infection control failures during wound care procedures, medication safety issues, and food service problems.
Critical Infection Control Violations During Wound Care
The most serious violations centered on improper infection control practices during wound care for residents with stage 4 pressure ulcers. Inspectors observed Licensed Practical Nurse #1 performing wound care for Resident #32, who had osteomyelitis (bone infection) of the spine and a stage 4 coccyx wound.
During the March 13 observation, the nurse failed to establish a clean field before beginning the procedure, placing supplies directly on the resident's bedside table. After removing the old dressing and cleaning fecal matter from the resident's anal area, the nurse changed gloves but failed to sanitize hands between steps. The nurse then contaminated the wound by cleaning from the outer area into the wound using supplies that had been placed on the potentially contaminated bedside table.
Similarly, Licensed Practical Nurse #5 violated sterile technique while changing a dressing for Resident #47's left trochanter wound. The nurse removed old dressing containing thick yellow drainage, then proceeded to clean the wound with multiple gauze pieces. During the cleaning process, the nurse repeatedly contaminated their sterile gloves by transferring gauze from clean hand to dirty hand, then touching the clean hand with the contaminated hand. This occurred four times during the procedure, yet the nurse never changed gloves after touching drainage from inside the wound.
Proper wound care protocols require establishing a clean field, hand sanitization between each step, and changing gloves immediately after contact with contaminated materials. These procedures prevent introducing harmful bacteria into open wounds, which can lead to serious infections, delayed healing, or life-threatening sepsis.
The facility's own wound care policy clearly stated that hands should be sanitized between glove changes and sterile gloves must be worn when physically touching wounds. Staff had received infection control training just one day before the observed violation occurred.
Medication Administration Safety Failures
Inspectors found multiple medication safety violations that could compromise resident care. A Licensed Practical Nurse was observed allowing a family member to administer medication to Resident #41, who has Alzheimer's disease. The nurse mixed Metamucil powder with water, handed it to the resident's wife, and left the room without observing consumption. The nurse then signed the medication administration record indicating the medication had been given.
This practice violates facility policy and professional standards. Family members should not administer medications without proper assessment, physician orders, and documented care plans. When family members give medications unsupervised, there is no verification the correct dose was consumed or that the resident didn't experience adverse effects.
Another nurse demonstrated improper insulin pen technique while preparing medication for a diabetic resident. The Licensed Practical Nurse drew 10 units of Humalog insulin without priming the pen with 2 units first, as recommended by the manufacturer. Failing to prime insulin pens can result in inaccurate dosing, potentially causing dangerous blood sugar fluctuations.
Medication storage violations were found throughout the facility, including insulin pens and vials without expiration dates, expired eye drops still in use, and discontinued medications not properly removed from carts. One insulin pen labeled as Degludec actually contained Novolog insulin, creating serious potential for dosing errors.
COVID-19 Isolation Protocols Ignored
Staff repeatedly left doors open to rooms housing COVID-19 positive residents who were supposed to be on droplet precautions. Rooms 54, 63, and 66 displayed proper isolation signage requiring personal protective equipment, but doors remained open after staff visits on multiple days.
Droplet precautions require closed doors because the infection can spread through airborne particles. Open doors allow contaminated air to circulate throughout the facility, potentially exposing other vulnerable residents and staff to COVID-19.
A Certified Nursing Aide acknowledged that "staff keeps forgetting to close the door" despite knowing the residents tested positive for COVID-19. A Registered Nurse Educator confirmed doors should remain closed and planned to re-educate staff about isolation protocols.
Food Service and Safety Concerns
Residents complained extensively about cold, unappetizing food that often didn't match their meal tickets. Resident #19 stated during a resident council meeting that "the food was always cold and not appealing or appetizing" and that "trays for meals never arrive on the unit at a consistent time."
When inspectors checked Resident #19's lunch on March 17, the meal ticket listed an egg salad sandwich, tossed salad, soup, mixed fruit, condiments, milk, dressing, and iced tea. Instead, the resident received corned beef and cabbage with potatoes, carrots, applesauce, milk, and ice cream - completely different from what was ordered.
Temperature testing revealed some food items below safe serving temperatures. Proper food temperatures ensure both safety and palatability - cold food may not only be unappetizing but can harbor harmful bacteria if not maintained at appropriate temperatures.
A Kitchen Supervisor admitted they were short-staffed and "did not have the time to portion out the items." The facility had run out of hard-boiled eggs for egg salad sandwiches but failed to inform residents about substitutions or offer alternatives.
Adaptive Equipment Shortages Impact Resident Independence
The facility failed to provide required adaptive eating utensils for Resident #38, who has dementia and needs built-up forks, knives, and spoons for independent eating. On multiple occasions, the resident received only some of the required adaptive equipment because "the kitchen did not have any more adaptive forks or knives."
Adaptive equipment enables residents to maintain dignity and independence during meals. Without proper utensils, residents may struggle to eat adequately, potentially leading to malnutrition or requiring unnecessary assistance.
Facility Response and Required Improvements
Director of Nursing #1 acknowledged that staff had received wound care training and that proper procedures were not followed. The facility must implement immediate corrective measures including staff re-education on infection control, medication administration, and isolation protocols.
The Administrator stated they were undergoing staff changes and working on menu improvements. However, fundamental safety protocols cannot wait for staffing stabilization - resident safety requires immediate attention to infection control, medication management, and food service standards.
These violations represent systemic issues requiring comprehensive staff training, policy enforcement, and management oversight to ensure resident safety and quality care at River Ridge Living Center.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Ridge Living Center from 2025-03-18 including all violations, facility responses, and corrective action plans.
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