River Ridge Living Center

F-F755-761 (Pharmacy Services) available. Manufacturer's instructions or user's manuals related to any medication administration devices are kept with the devices or at the nurses' station.

Resident #41:

Resident #41 was admitted to the facility with diagnoses of Alzheimer Disease (a progressive brain disorder that primarily causes memory loss and thinking difficulties), osteoarthritis (when the cartilage that cushions

the ends of bones in your joints gradually deteriorates), and constipation. The Minimum Data Set (an assessment tool) dated 1/29/2025, documented resident had moderate cognitive impairment, could be understood, and understand others.

During an observation on 3/12/2025 at 11:45 AM, A Wing CART 1, Licensed Practical Nurse #5 mixed 1 teaspoon of Metamucil powder in 4 ounces of water. They brought the medication to Resident #41's room and gave the medication to Resident #41's wife to administer to the resident. Licensed Practical Nurse #5 left

the room and closed the door without observing resident consuming prescribed medication. They then signed that the medication had been administered in the medication administration record.

During an interview on 3/12/2025 at 11:47 AM, Licensed Practical Nurse #5 stated Resident #41's wife was very demanding and difficult. They always gave them the medication to administer to avoid any conflict.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 During an interview on 3/12/2025 at 12:10 PM, Licensed Practical Nurse #6 along with Registered Nurse #2 and Registered Nurse #3 stated family members were not allowed to administer medications. There were no Level of Harm - Minimal harm or exceptions at this time. Director of Nursing #1 stated at no time should family members administer potential for actual harm medications without a resident assessment, family member assessment, and physician order. If there were any exception, the resident would have a care plan in place and orders would be in the medication Residents Affected - Some administration record.

Resident #80:

Resident #80 was admitted to the facility with diagnoses of diabetes mellitus type 1 (chronic condition that affects the insulin making cells of the pancreas),chronic kidney disease (loss of function in the kidneys), and hypertension (when the pressure in blood vessels is too high). The Minimum Data Set, dated dated dated [DATE REDACTED], documented resident was cognitively intact, could be understood, and understand others.

During an observation on 3/12/2025 at 11:21 AM, A wing CART 2, Licensed Practical Nurse #7 drew 10 units of Humalog using an insulin Kwik Pen that was prescribed for Resident #80. They did not prime the pen with 2 units of insulin prior to drawing the prescribed amount as recommended by manufacturer.

During an interview on 3/12/2025 at 11:21 AM, Licensed Practical Nurse #7 stated they were unaware that

they should prime pen with each use. Instead, they had the understanding that priming pen was only required for initial use only.

During an interview on 3/13/2025 at 01:01 PM, Director of Nursing #1 stated each nurse received training upon hire for medication administration including the administration of insulin. New hire nurses were assigned to a preceptor who observed, mentor, and signed off on medication administration competency prior to administering medication independently.

10 New York Codes, Rules, and Regulations 415.12 (m)(1)]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48615 Residents Affected - Some Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for three (3) ( A, B, and C Wings) of three (3) medication carts, and 1 (C Wing) of 2 medication rooms reviewed. Specifically, (a.) 1 Novolog Kwik insulin pen was in a bag labeled Degludec insulin; (b.) 8 insulin kwik pens and 3 vials of insulin had no open and or expiration dates; (C.) 2 bottles of Megace liquid were discontinued; (d.) 3 inhalers had no open and or expiration dates; (e.); 3 bottles of eye drops had no open and or expiration dates; (f.) 1 bottle of eye drops opened [DATE REDACTED], expired as of [DATE REDACTED]; (g.) 1 opened bottle of Jevity Tube feed with 200 milliliters remaining was found in the medication room refrigerator; (h.) 1 black extra-large ice pack belonging to a discharged resident was found in the medication room refrigerator. 1 crate overflowing with discontinued medications were found in the medication room.

This is evidenced by:

The facility's Policy and Procedure titled Administering Medications updated ,d+[DATE REDACTED], documented the facility stores all drugs and biologicals in a safe, secure, and orderly manner. #12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. #17. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident.

The facility's Policy and Procedure titled Storage of Medication revised ,d+[DATE REDACTED], documented #4. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

During an observation on [DATE REDACTED] at 10:49 AM, A Wing, Medication Cart 1 contained 1 Degludec insulin pen inside of a bag labeled Novolog Kwik pen with no open and or expiration dates; 1 Novolog, 1 Basaglar, 3 Humalog, and 1 Tresiba insulin pens, along with 2 Lantus vials had no open or expiration dates. 2 bottles of Megace liquid, discontinued as of [DATE REDACTED].

During an observation on [DATE REDACTED] at 3:02 PM, C Wing Medication Cart contained 1 lispro insulin pen, 1 Humalog insulin pen and 1 Humalog insulin vial with no open and or expiration dates. 1 bottle of Latanoprost 0.05% eye drops opened [DATE REDACTED], expired as of [DATE REDACTED]. 1 bottle Artificial tears, and 1 Budesonide inhaler had no open and or expiration dates.

During an observation on [DATE REDACTED] at 11:52 AM, B Wing Medication Cart contained 1 bottle of Lumigan 0.01% eye drops, 1 bottle of artificial tears eye drops, 1 Budesonide inhaler, and 1 Albuterol inhaler with no open and or expiration dates.

During an observation on [DATE REDACTED] at 12:20 PM, C Wing Medication Room Refrigerator contained 1 opened bottle of Jevity Tube feed with 200 milliliters remaining; 1 black extra-large ice pack belonging to a discharged resident and 1 crate overflowing with non-narcotic discontinued medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Licensed Practical Nurse #1 stated the nursing supervisor collected discontinued medications weekly but was not sure when they last collected discontinued medications. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE REDACTED] at 1:01 PM, Director of Nursing #1 stated it was the responsibility of each nurse assigned to a medication cart to ensure the cart was clean and orderly. All nursing staff must check Residents Affected - Some the expiration date of any medication before administering. All multi-dose insulin medications should be labeled with both open and expiration dates. During new hire orientation all nurses are made aware of medications with shortened expiration dates after opening that includes insulins, inhalers and eye drops. Director of Nursing #1 stated discarded medications were to be packed up daily and brought to the supervisor. Any unused tube feed should be discarded.

10 New York Codes, Rules, and Regulations 415.18(d)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 36922 potential for actual harm Based on observations, record reviews, and interviews during a recertification and abbreviated survey (Case Residents Affected - Some #'s NY00349575 and NY00370532), the facility did not ensure that food and drink were palatable and attractive for two (2) (Residents #19 and 32) of 11 residents reviewed for palatable and appealing food and drink. Specifically, (a.) residents complained that the food was cold, unattractive, and generally unpalatable

during the resident council meeting; (b.) Resident #19's lunch tickets did not match what the resident received during their lunch service on 3/17/2025; (c.) Resident #32 complained of cold, unattractive, and not palatable food, and during lunch service on 3/13/2025, the resident's food tray did not match their ticket

This is evidenced by:

A facility policy titled Food and Nutrition Services, dated 1/2024, documented that the facility would provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, considering each resident's preferences.

Resident # 19:

Resident # 19 was admitted to the facility with diagnoses of heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), chronic kidney disease, stage 3 (kidneys have mild to moderate damage, meaning they are less effective at filtering waste and fluid from your blood), and chronic obstructive pulmonary disease (a group of lung diseases that cause progressive and irreversible airflow obstruction, leading to breathing difficulties). The Minimum Data Set (an assessment tool) dated 3/28/2025 documented that the resident had intact cognitive ability, could be understood and understood others.

During the resident council meeting on 3/12/2025 at 11:00 AM, Resident #19 stated that the food was always cold and not appealing or appetizing. Resident #19 stated that the trays for meals never arrive on the unit at

a consistent time. They stated that they did not bother for staff to reheat their food, as it would take a long time to get it back. They stated that items are always wrong and missing when the trays arrive for meals.

During an observation on 3/17/2025 at 12:24 PM, Resident #19 was to receive a whole egg salad sandwich, half cup of tossed salad, 6 ounces of chef's choice soup, half cup of mixed fruit, two packets of mustard and mayo each, two containers of 1% milk, a packet of thousand island dressing, and 4 ounces of iced tea. In comparing the lunch ticket and meal tray, the resident received corned beef and cabbage with potatoes, carrots, applesauce, milk, and chocolate ice cream. The resident did not receive any items that were documented on their lunch ticket, except for one container of 1% milk.

During a test tray on 3/17/2025, the temperature and taste of Resident #19's lunch were assessed. The corned beef and cabbage were at 114.1 degrees Fahrenheit and tasted as expected. The beef was easily chewed and broken down. The carrots were at 108.5 degrees Fahrenheit and tasted as expected. The potatoes were at 119.7 degrees Fahrenheit and tasted as expected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Kitchen Supervisor #1 was interviewed on 3/17/2025 at 12:59 PM after they brought the replacement tray to Resident #19. Resident #19's replacement tray did not match the resident's lunch ticket. Kitchen Supervisor Level of Harm - Minimal harm or #1 stated that they had been short-staffed and did not have the time to portion out the items. They stated that potential for actual harm the facility ran out of hard-boiled eggs to make the egg salad sandwiches last Thursday. They stated that

they had given the resident the regular meal for lunch, even though their lunch ticket documented that they Residents Affected - Some had requested a substitute. They stated that they did not mention the lack of requested items to the resident and did not ask if they would like a different substitute since the facility did not have the requested item.

Resident # 32:

Resident #32 was admitted to the facility with diagnoses of heart failure (a chronic condition in which the heart does not pump blood as well as it should), diabetes mellitus, and osteomyelitis of the spine (bone infection from an open wound that is infected). The Minimum Data Set (an assessment tool) dated 1/31/2025, documented that the resident could be understood and understand others with intact cognition for decisions of daily living.

A review of Resident #32's diet documented that the resident was initially ordered a regular diet with thinned liquids upon admission on 1/24/2025.

Review of Resident #32's Comprehensive Nutritional Care Plan, implemented on 1/24/2025, documented a potential alteration in nutritional status related to obesity, infection, gastroesophageal reflux disease, and iron deficiency. Goals stated as follows: A. The resident will consume greater than 75 percent of each meal. B.

The resident will state their food preferences and tolerances. Interventions: A. Diet as ordered by the medical doctor. B. Provide an appropriate, consistent diet. C. Provide nutritional supplements and nourishments as tolerated by the resident. Last updated on 1/27/2025.

Dietary meal ticket dated 3/13/2025 for Resident #32 documented 4 oz beef ravioli, 4 ounces zucchini, one piece apple coffee cake, 2 percent milk, 8 ounces coffee, one package sugar, one package pepper, and one creamer,

During an observation on 3/13/2025 at 12:15 PM, Resident #32's food tray was delivered. It consisted of noodles with a butter sauce, green beans, milk, and coffee cake. The resident was observed to eat about 25 percent of the meal. The green beans were mushy, and the sauce on the noodles was not marinara as stated on the ticket. The noodles were overcooked and mushy, and the butter was congealed, appearing semi-solid and unappetizing.

During an interview on 3/13/2025 at 12:45 PM, Resident #32 stated that the food was not what they had ordered. They further stated that the meal was cold, the milk was warm, and they had not received coffee. Resident #32 stated that the food was always cold and mostly inedible so that the family would bring them food. They had complained, but nothing had changed.

During an interview on 3/13/2025 at 12:57 PM, Certified Nurse Aide #1 stated that one of the biggest complaints they received from the resident was cold food. They stated the food on the tray did not always match what was on the ticket. They stated they sometimes would get the resident a sandwich if the resident asked. If the kitchen run out of a particular food on the menu, they substituted something else.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During an interview on 3/17/2025, at 12:42 PM, Registered Dietician #1 stated residents should be informed of food substitutions before trays arrive, allowing them to participate in the substitution. Registered Dietician Level of Harm - Minimal harm or #1 stated they would review the resident because they had a wound and look to add nutritional drinks and potential for actual harm protein. They further stated they were not familiar with the resident and would meet with them later to review their concerns and preferences. Registered Dietician #1 was unsure about staff training but stated that the Residents Affected - Some person who brought the tray to the resident should have checked to ensure the food ticket matched what was on the tray and asked the resident if it was acceptable.

During an interview on 3/18/2025, at 11:07 AM, Administrator #1 stated that they had been undergoing changes with staff in the facility. Food complaints were common, and they were working on the menu. They stated staff should verify that meal tickets match the food on the trays. If a resident did not like the food or said it was cold, a new tray should be ordered.

10 New York Code of Rules and Regulations 415.14(d)(1)(2)

48413

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Level of Harm - Minimal harm or 48413 potential for actual harm Based on observation, record review, and interviews during the recertification survey, the facility did not Residents Affected - Some ensure that special eating equipment and utensils were provided for one (1) (Resident #38) of seven (7) residents reviewed for dining. Specifically, for Resident #38, adaptive eating equipment was not provided to maintain or improve the resident's ability to eat independently.

This is evidenced by:

Resident #38 was admitted to the facility with unspecified dementia (a decline in mental ability severe enough to interfere with daily life), essential (primary) hypertension (persistent high blood pressure), and type 2 diabetes mellitus (a chronic condition where the body does not use insulin effectively or does not produce enough insulin, leading to high blood sugar levels). The Minimum Data Set (an assessment tool) dated 2/15/2025 documented the resident had moderate impairment in cognition, was able to make themselves understood, and was usually able to understand others.

During an observation on 3/11/2025 at 1:02 PM, Resident #38 was eating lunch in the common area. Resident #38 had their build-up spoon but did not have their adaptive built-up fork, and when asked if they had the adaptive fork, they stated that they did not and sometimes did not receive it.

During an observation on 3/12/2025 at 9:32 AM, Resident #38 had one built-up spoon and one regular curved spoon. The resident's breakfast ticket documented that the resident was to have a built-up fork and a built-up spoon.

A review of the resident's comprehensive care plan titled, Activities of Daily Living: Reduced Activities of Daily Living and dated 7/10/2023, documented adaptive devices/supportive equipment would be provided as per physical therapy /occupational therapy recommendation, built up fork, knife, and spoon with meals.

A review of the resident's comprehensive care plan titled, Nutritional Status/Hydration and dated 7/10/2023, documented adaptive devices/supportive equipment would be provided as per physical therapy /occupational therapy recommendation built up fork, knife, and spoon with meals.

A review of the resident's Certified Nurse Aide's daily care card for eating on 3/13/2025 documented that the resident required partial or moderate assistance to provide adaptive feeding devices: a built-up fork, built-up spoon, built-up knife, and scoop dish.

During an interview on 3/12/2025 at 9:45 AM, Certified Nurse Aide #9 stated that according to the ticket, Resident #38 was to have built-up utensils for eating assistance. They further stated that Resident #38 did not have that item today; that it was dependent on whether or not the kitchen had adaptive utensils available.

They stated the resident sometimes did not receive them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 During an interview on 3/18/2025 at 10:05 AM, Registered Nurse #3 stated staff were to check meal trays and meal tickets for accuracy before bringing the trays to the residents. They stated staff were to call the Level of Harm - Minimal harm or kitchen if any items were incorrect or missing. They stated staff should have discovered the missing adaptive potential for actual harm equipment on the resident's tray, called the kitchen, and held the tray until the missing equipment arrived.

Residents Affected - Some During an interview on 3/12/2025 at 10:36 AM, Kitchen Supervisor #1 stated that Resident #38 had one built-up spoon and one regular curved spoon because the kitchen did not have any more adaptive forks or knives. They stated that recently, they noticed residents were missing adaptive utensils; they believed more had been ordered but were unsure when the items would arrive. They stated that it was difficult to replace

the missing items when the kitchen did not have them.

10 New York Code of Rules and Regulations 415.14(g)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 21414

Residents Affected - Some Based on observation, record review, and interview during the recertification survey, the facility did not ensure food was stored, prepared, distributed, or served food in accordance with professional standards for food service safety in the main kitchen and two (2) of three (3) kitchenettes. Specifically, equipment, floors, and walls were not clean and/or were in good repair, and the facility did not have the correct equipment to test the chemical sanitizing solution.

This is evidenced by:

During observations of the main kitchen on 3/11/2025 at 10:18 AM, the following was noted:

1. Test papers to check the sanitizing solution did not have a graduation of 150 parts per million of quaternary ammonium compound graduation and another above 400 parts per million of quaternary ammonium compound. The efficacy range as stated on the sanitizer concentrate label was between 150 and 400 parts per million of quaternary ammonium compound.

2. The following items were soiled with food particles:

Bulk food containers.

Shelving.

Sheet pan rack.

Stoves.

Floor under cooking line equipment.

Shelving under serving line.Underside of dining room tables.

During observations of the A-Wing kitchenette on 3/11/2025 at 11:16 AM, the following was noted:

The microwave oven, refrigerator, floor in corners, and bathroom floor were soiled with food particles and/or dirt. Plastic panels in the freezer section of refrigerator were covered with white duct tape. The walls were scraped, and one hole was found above microwave oven.

During observations of the B-Wing kitchenette on 3/11/2025 at 11:21 AM, the following was noted:

The walls, floor in corners, and bathroom floor were soiled with food beverage splashes and/or dirt.

Plastic panels in the freezer section of refrigerator were covered with white duct tape.

The walls were scraped and had 4 holes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During an interview on 3/11/2025 at 2:50 PM, Administrator #1 stated that they would speak with the dietary, housekeeping, and maintenance staff about cleaning and about the noted maintenance items. Level of Harm - Minimal harm or potential for actual harm 10 New York Codes, Rules, and Regulations 415.14(h)

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or 21414 potential for actual harm Based on observation, record review, and interview during the recertification survey, the facility did not Residents Affected - Some ensure food brought for residents by family or visitors was stored safely and in a way that is either separate or easily distinguishable from facility food on one (1) (A-Wing Unit) of three (3) resident units. Specifically, resident food stored in the resident unit kitchenette refrigerators was not properly labeled.

This is evidenced by:

The document titled, Food Brought by Family/Visitors and dated 11/2024, documented that food brought to residents are to be labeled with the resident name, date, and use-by date.

During observations on the A-Wing Kitchenette on 3/11/2025 at 11:16 AM, two restaurant entrees were not labeled and dated.

During an interview on 3/11/2025 at 2:51 PM, Administrator #1 stated that the staff should label food brought to residents with the resident name, date received, and the date to discard the food. They further stated that staff would be re-educated on labeling food brought to residents.

10 New York Codes, Rules, and Regulations 415.14(h)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36922 potential for actual harm Based on observation, interview, and record review during a recertification and abbreviated survey (Case Residents Affected - Some #NY00349575), the facility did not ensure it established and maintained an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and did not maintain infection control prevention during dressing changes for two (2) (Resident #s 32 and 47) of four (4) residents reviewed for pressure sores. Specifically: (a.) for Resident #32, Licensed Practical Nurse #1 did not set up and maintain a clean field and proper infection control that included proper hand hygiene was performed, during a dressing change to prevent contamination of a resident's wound; (b.) for Resident #47, Licensed Practical Nurse #5 did not change gloves and hand sanitize during the dressing change; (c.) Staff did not maintain isolation precautions by closing doors to isolation rooms with residents who were positive for Covid 19 and on droplet precautions; (d.) the facility did not complete a water system environmental assessment for Legionella within the past year.

This is evidenced by:

The facility's policy titled Wound Care, last revised 3/2024, documented the following:

1. Use disposable cloth (paper towel was adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached.

2. Wash and dry your hands thoroughly.

3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect

the bed linen and other body sites.

4. Put on exam glove. Loosen tape and remove dressing.

5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly, put

on gloves.

6. Put on gloves. Change gloves and hand sanitize between cleansing of the wound.

7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers.

8. Pour liquid solutions directly on gauze sponges on their papers.

9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound.

10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 12. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. Be certain all clean items are on clean field. Level of Harm - Minimal harm or potential for actual harm 13. Remove the disposable cloth next to the resident and discard into the designated container.

Residents Affected - Some 14. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, handwash into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.

(a.) Resident #32:

Resident #32 was admitted to the facility with diagnoses of heart failure (a chronic condition in which the heart does not pump blood as well as it should), obstructive sleep apnea (a sleep disorder where breathing stops during sleep due to a blockage in the airway causing a decrease in oxygen delivery to the body), and osteomyelitis of the spine (bone infection from an open wound that is infected). The Minimum Data Set (an assessment tool) dated 1/31/2025, documented that the resident could be understood and understand others and was cognitively intact for decisions of daily living.

A Physician Order dated 1/31/2025 documented the following: Cleanse sacral wound with Dakin ' s solution 0.125 percent, apply calcium alginate packing to base of wound, secure with silicone border suprabasorb twice daily and prn (as needed).

Review of Resident #32 Comprehensive Care Plan for pressure ulcer and wound care dated 1/24/2025, documented the goal was resident would not experience complications of infections, or concerns.

The Electronic Treatment Administration Record for March 2025 documented the following: Dakin ' s Solution 0.125 percent, cleanse sacral wound with Dakin ' s solution per treatment, order 2 times a day for osteomyelitis of vertebra, sacral and sacrococcygeal region. Start date 1/31/2025.

During an observation on 3/13/2025 at 11:30 AM, Licensed Practical Nurse #1 with the assistance of Certified Nurse Aide #6 performed wound care for Resident #32 on their stage 4 coccyx wound. Licensed Practical Nurse #1 brought dressing supplies into the room and placed them on the resident ' s bedside table. They washed their hands with soap and water for 10 seconds, dried them, put gloves on and removed

the old dressing, changing their gloves they proceeded to clean the resident from a recent bowel movement.

After cleaning the residents peri area, Licensed Practical Nurse #1 placed soiled washcloths in a bag on the bed. They changed their soiled gloves and began cleaning the wound on the coccyx with gauze using wound supplies that had been placed on the bedside table. Licensed Practical Nurse #1 did not sanitize their hands between glove changes after having removed the old dressing, cleaning the feces from the resident ' s anus, and placing the old, soiled dressing into the garbage. Licensed Practical Nurse #1 contaminated the wound when cleansing the wound going from outer area into the wound. They changed their gloves and placed the calcium alginate (a dressing for wound healing) in the wound and applied a dry clean silicone border dressing to Resident #32 ' s coccyx without hand sanitizing before each step.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 3/17/2025 at 11:10 AM, Licensed Practical Nurse/Infection control preventionist #1 stated the first step in preparing for a dressing change was to prepare a clean field. Staff had recently been Level of Harm - Minimal harm or educated on wound care. Hands should have been sanitized between glove changes for each step potential for actual harm especially if the resident had visibly soiled areas around the wound. Dressing material should have been opened and placed on the clean field and gloves should have been changed because the outside of the Residents Affected - Some package was considered dirty. Licensed Practical Nurse #1 would have to be reeducated about clean technique during a dressing change.

During an interview on 3/18/2025 at 11:47 AM, Licensed Practical Nurse #1 stated they had not realized they had contaminated their gloves several times during the dressing change for Resident #32. They acknowledged they had not followed proper wound care procedure while putting on and removing and gloves. Hands should have been sanitized between steps, gloves changed, and they should have prepared a clean field before beginning the wound care.

During an interview on 3/17/2025 at 2:17 PM, Director of Nursing #1 stated the Licensed Practical Nurses had been trained on wound care. The Licensed Practical Nurse/ Infection Control Preventionist #1 was certified to monitor the infections in the facility and to monitor and do audits and evaluate staff performance

on wound care. There was a shortage of Registered Nurses, and properly trained Licensed Practical Nurses should have been able to perform this task. A clean field was the first thing that should be done before beginning wound care. Items and supplies should not have been used once they were placed in the nurse ' s pocket. Sanitizing of the hands should have been done before putting clean gloves on before each step in

the procedure.

(b) Resident #47:

Resident #47 was admitted to the facility with diagnoses of paraplegia, unspecified (paralysis that affects the legs, making it impossible to stand or walk), diabetes mellitus (The body ' s ability to produce or respond to

the hormone insulin was impaired), and cellulitis (local skin infection) of lower extremities. The Minimum Data Set, dated dated dated [DATE REDACTED], documented Resident #47 could understand and be understood by others with intact cognition for decisions of daily living.

Physician Order dated 4/12/2024, renewed monthly to current, documented wound care to left trochanter: Cleanse with 0.125% Dakin ' s solution. Apply hydrocortisone to peri wound; collagen and alginate packing to base of the wound; apply superabsorbent silicone and cover with foam dressing.

During an observation on 3/18/2025 at 9:44 AM, Licensed Practical Nurse #5 performed a dressing change of left trochanter for Resident #47. Licensed Practical Nurse #5 removed the old dressing which was noted to have a moderate amount thick yellow drainage on the gauze. After removing old dressing, Licensed Practical Nurse #5 removed the old gloves and applied sterile gloves. They cleansed the wound using multiple 4 x 4 gauze. Licensed Practical Nurse #5 wiped inside of the dirty wound with right hand then exchanged gauze from left clean hand into soiled right hand, contaminating left hand. They repeated the steps 4 times, dirty hand touching clean hand, then applied packing gauze inside of the wound. After they applied packing to the wound, they removed the packing, stating it was wrong size. They cut a new piece of packing and re-applied. Sterile gloves were not changed at any time after touching drainage and contents from inside of the wound.

The wound was covered with a dry dressing. Licensed Practical Nurse #5 stated the wound was assessed and measured by the Wound Care Team.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 3/18/2025 at 10:08 AM, Registered Nurse #4 stated nursing staff completed an infection control training including dressing changes the previous day, 3/17/2025. Licensed Practical Nurse Level of Harm - Minimal harm or #5 was in attendance. In addition, Infection Control and Prevention was covered during new hire orientation. potential for actual harm (c.) Finding: Doors to rooms designated for isolation for Covid Positive Residents were not closed. Residents Affected - Some Signage on room # ' s 54 ,63, and 66 carried the following notification: Droplet Precautions with Personal Protective Equipment Usage and hand washing instructions, Quarantine Room precautions and instructions prior to entering room, and contact precautions and instruction for all staff before entering and before exiting.

During observation on 3/11/2025 from 9:45 AM and 12:35 PM, Covid rooms on the rehabilitation unit were observed to be left open by staff who went into the room to deliver care. Room #s 54, 63 and 66 were left open after staff exited rooms.

During observation on 3/12/2025 from 9:45 AM and 12:35 PM, Covid rooms on the rehabilitation unit were observed to be left open by staff who went into the room to deliver care. Room # ' s 54, 63 and 66 were left open after staff exited rooms.

During an interview on 3/12/2025 at 12:35 PM, Certified Nursing Aide #1 stated the staff keeps forgetting to close the door after they take off their personal protective equipment but that the doors should have been closed because the residents had tested positive for Covid 19 and were on isolation.

During an interview on 3/12/2025 at 1:07 PM, Registered Nurse Educator #5 stated the doors to the isolation rooms should be closed. Droplet precautions meant an infection was airborne and could be spread in the air.

They did not know why the staff had not maintained infection control but would start to reeducate staff about

the importance of closing the doors of the rooms with signage that designated the resident was on precautions.

(d) Legionella

Finding #1: Water Management and Sampling Plan

There was no documented evidence that the facility developed a Water Management and Sampling Plan.

During an interview on 3/13/2025 at 10:21 AM, Consultant #1 stated that they would search the facility files for a Water Management and Sampling Plan and would develop one if it could not be found.

Finding #2: Water System Environmental Assessment

There was no documented evidence that the facility completed a water system environmental assessment for Legionella within the past year.

During an interview on 3/12/2025 at 12:29 PM, Administrator #1 stated that the last facility risk assessment for legionella was completed on 1/11/2024, and another assessment would be completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 10 New York Codes, Rules, and Regulations 415.19(a), 483.65

Level of Harm - Minimal harm or 48615 potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 59 335422 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335422 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Ridge Living Center 100 Sandy Drive Amsterdam, NY 12010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 21414 potential for actual harm Based on observation, record review, and interviews during the recertification survey, the facility did not Residents Affected - Some maintain a pest-free environment and an effective pest control program on one (1) of six (6) resident units. Specifically, small fly infestation was found.

This is evidenced by:

During observations on 3/11/2025 from 10:15 AM through 12:35 PM,

Little black flies were found in the corridors by Room #s 54, 57, 62, and 73.

Little black flies were found flying around a resident with a feeding tube on the C-Wing.

During observations on 3/12/2025 at 9:45 AM, little black flies were found flying around staff serving meal trays.

During an interview on 3/11/2025 at 11:30 AM, Family Member #10 stated that the fly infestation was so bad

they covered the television in the resident room and that it helped when the trash was removed from the room.

During an interview on 3/12/2025 at 12:15 PM, Certified Nurse Aide #3 stated there have been black flying bugs since they were hired, and that though the facility had a pest control vendor, the problem was worse on some days more than other days.

During an interview on 3/13/2025 at 1:59 PM, Administrator #1 stated that they were aware of the fly problem

on the C-Wing, a pest control vendor had treated for this issue last week and staff would need to take the after-meal trays off the units much earlier than is done presently.

10 New York Codes, Rules and Regulations 415.29(j)(5)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 59 335422