Northern Riverview Health Care, Inc

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

PM, the family representative stated that when they visited on 08/29/2025, they observed that Resident #1's right eye was red and reported this to the nurse. The family representative stated that the nurse informed them that the redness was already addressed, that the resident had an infection related to an allergic reaction to medication, and that the issue had been handled. The family representative stated that

they had not been contacted by staff prior to their visit about any redness or change in the resident's condition. 10NYCRR 415.3

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northern Riverview Health Care, Inc

87 South Route 9w Haverstraw, NY 10927

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 0609 Level of Harm - Minimal harm or potential for actual harm

resident. The complainant stated that they contacted law enforcement because they believed that Resident #1 was not safe, and that the facility did not report the allegation to the Department of Health. 10 NYCRR 415.4(b)(1)(ii)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northern Riverview Health Care, Inc

87 South Route 9w Haverstraw, NY 10927

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 0610

415.4(b)(1)(ii)

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northern Riverview Health Care, Inc

87 South Route 9w Haverstraw, NY 10927

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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

ciprofloxacin ophthalmic antibiotic eye drops on 08/29/2025 for Resident #1's right-eye redness without completing a nursing assessment or documenting any evaluation or assessment of the resident's condition.

Registered Nurse Supervisor #1 stated that there were no clinical indications documented to support why

the resident would need antibiotic eye drops. When asked where the care plan interventions were for the Resident #1's right-eye redness, Registered Nurse Supervisor #1 stated that they were probably rushing to complete an admission and that interventions should have been added on the care plan. Registered Nurse Supervisor #1 stated that every time there is a change in condition, the care plan should be updated to reflect new interventions and appropriate goals. 10 NYCRR 415.11(c)(1)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northern Riverview Health Care, Inc

87 South Route 9w Haverstraw, NY 10927

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

05:01 PM, the Director of Nursing stated they were not employed at the facility when the redness to Resident #1's right eye was first reported on 08/29/2025. The Director of Nursing was unable to provide documented evidence of any nursing assessment, provider notification, or clinical rationale supporting the initiation of ciprofloxacin ophthalmic eye drops for the reported right-eye redness of Resident #1. During an

interview on 10/29/2025 at 04:40 PM, Physician #1 stated they were aware that ciprofloxacin ophthalmic drops were ordered for Resident #1 on 08/30/2025 but did not assess the resident at that time. Physician #1 stated they first evaluated the resident on 09/13/2025 and relied on the diagnosis of subconjunctival hemorrhage previously documented by the nurse practitioner on 09/04/2025. Physician #1 stated they did not know why no assessment or clinical documentation was not completed when the redness was first reported on 08/29/2025. During an interview on 10/29/2025 at 05:16 PM, the family representative stated

they observed redness to the resident's right eye on 08/29/2025 and reported it to the nurse on duty. The family representative stated they were told the condition had already been addressed. The Family representative stated they did not receive any notification before their visit on 08/29/2025. 10 NYCRR 415.12(c)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northern Riverview Health Care, Inc

87 South Route 9w Haverstraw, NY 10927

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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interviews conducted during an Abbreviated Survey (2622688), the facility did not ensure physician supervision oversight of medical care for one (Resident #1) of (3) three residents reviewed for physician services. Specifically, an order for ciprofloxacin(antibiotic) eye drops was ordered for Resident #1's right eye on 08/29/2025 after redness was reported by family representative. There was no documented physician assessment or nursing assessment at the time the order was entered. The treatment began 08/30/2025, and Resident #1 was not evaluated by a medical provider until 09/04/2025 six days after

the change in condition was identified and after treatment had already been initiated.The findings include:The facility policy titled Physician Services, revised 05/2019 documented that a physician shall

review and document orders for the care and treatment of residents and shall evaluate residents as clinically indicated. The policy also stated that all verbal orders must be authenticated by the physician.

Resident #1 was admitted with diagnoses including dementia, anemia, and cardiac arrhythmias. The Minimum Data Set, dated [DATE REDACTED] documented that the resident had severe impaired cognition and required extensive assistance of one staff for toileting, personal hygiene, and bathing. Record review of the physician's orders dated 08/29/2025 documented that ciprofloxacin 0.3% ophthalmic drops, one drop to the right eye three times daily was created by Registered Nurse Supervisor #1 with a start date of 08/30/2025.

The order did not contain documentation of physician notification or assessment of the resident's change in condition. The medication administration record showed the eye drops was first administered on 08/30/2025. An initial Optum visit progress note dated 09/04/2025 at 11:06 AM documented that the resident was evaluated by a nurse practitioner and diagnosed with a subconjunctival hemorrhage to the right eye. The note did not reference the prior order for antibiotic eye drops. The note did not document response to treatment, and did not include an assessment of the resident at the time the antibiotic eye drops was initiated. During an interview on 10/29/2025 at 03:28 PM, Registered Nurse Supervisor #1 stated that ciprofloxacin(antibiotic) eye drops were ordered after a nurse notified them that the family representative for Resident #1 reported that the resident's eye appeared red. Registered Nurse Supervisor #1 stated they contacted the physician by text message to obtain the order but did not complete or document a nursing assessment of the resident and did not document physician notification in the medical record. Registered Nurse Supervisor #1 stated they could not recall the appearance of the resident's eye at

the time the order was entered. During an interview on 10/29/2025 at 02:56 PM, the Medical Director stated that physicians may not evaluate a resident immediately if they are unavailable or on vacation and that the covering provider may also be busy. When asked whether a resident receiving antibiotic eye drops should be assessed by a medical provider, the Medical Director stated they were unaware that six days had passed between when the order was first initiated and the first provider evaluation. During an interview on 10/29/2025 at 04:40 PM, Physician #1 stated that nurse practitioners are in the facility every day and that

they generally expect residents with a change in condition to be seen within two days. Physician #1 confirmed there was no documented evaluation of Resident #1 between 08/29/2025 and 09/04/2025 and stated that they had instructed staff to refer the resident to an ophthalmologist, but did not know whether

the resident was ever seen. No documentation of an ophthalmology referral or visit was found in the medical record. 10 NYCRR 415.15(b)(1)(i)-(ii)

Event ID:

Facility ID:

If continuation sheet