Inspection Reports for Adira at Riverside Rehabilitation and Nursing
120 Odell Ave, Yonkers, NY, 10701
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 17, 2025
Visit Reason
The abbreviated survey was conducted based on record review and interviews to assess the facility's compliance with accident hazard prevention and resident supervision to prevent falls.
Findings
The facility failed to ensure that all residents were free from accident hazards and that residents received adequate assistance to prevent falls. Specifically, Resident #1 sustained a head injury after a fall from bed, resulting in actual harm. The investigation revealed improper turning technique by staff and lack of side rails or grab bars on the bed.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in actual harm to Resident #1 after a fall from bed.
Report Facts
Residents reviewed for accidents: 3
Residents affected: 1
Fall incident date: Aug 5, 2025
Blood pressure: 162
Pulse rate: 121
Respiration rate: 20
Temperature: 97.7
Oxygen saturation: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Named in fall incident and investigation for improper turning technique leading to resident fall | |
| Nursing Supervisor #1 | Completed fall incident report and progress notes; involved in resident assessment after fall | |
| Medical Director | Reviewed hospital CT scan results and provided medical opinion on timing of subarachnoid hemorrhage | |
| Assistant Director of Nursing | Completed summary of investigation regarding resident fall | |
| Director of Nursing | Interviewed regarding resident fall and subsequent actions |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 22
Date: Aug 30, 2024
Visit Reason
Multiple Level 2 deficiencies related to quality of care and life safety code, including care plan timing, immunizations, infection control, nursing staff sufficiency, and pressure ulcer treatment (Level 3). All deficiencies corrected by late October 2024.
Findings
Multiple Level 2 deficiencies related to quality of care and life safety code, including care plan timing, immunizations, infection control, nursing staff sufficiency, and pressure ulcer treatment (Level 3). All deficiencies corrected by late October 2024.
Deficiencies (22)
Care plan timing and revision
Covid-19 immunization
Food procurement, store/prepare/serve-sanitary
Increase/prevent decrease in ROM/mobility
Infection prevention & control
Influenza and pneumococcal immunizations
Notify of changes (injury/decline/room, etc.)
Nurse aide performance review-12 hr/yr in-service
Respiratory/tracheostomy care and suctioning
Sufficient nursing staff
Treatment/services to prevent/heal pressure ulcer
Cooking facilities
Discharge from exits
Egress doors
Electrical systems - essential electric system
Emergency lighting
Gas equipment - cylinder and container storage
Gas equipment - liquid oxygen equipment
Hazardous areas - enclosure
Illumination of means of egress
Smoking regulations
Subdivision of building spaces - smoke barrier
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Aug 30, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey from 8/26/24 to 8/30/24 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to promptly notify resident representatives of changes, incomplete care plan updates for pressure ulcers, inadequate pressure ulcer prevention and care, insufficient nursing staff, lack of proper respiratory care, failure to maintain infection prevention and control programs, and failure to provide and document vaccinations for residents and staff.
Deficiencies (11)
Failure to promptly notify a resident's representative of a change in condition for 1 of 28 residents (Resident #38) regarding pneumonia and antibiotic initiation.
Failure to ensure comprehensive care plans were reviewed and revised timely to reflect changing needs for 1 of 4 residents (Resident #24) with skin impairments.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for 1 of 4 residents (Resident #24), resulting in an unstageable pressure ulcer and actual harm.
Failure to provide appropriate care to maintain or improve range of motion and mobility for 3 of 3 residents (Residents #24, #54, #91) due to lack of use of hand rolls.
Failure to provide necessary respiratory care consistent with physician orders for 1 of 4 residents (Resident #308) receiving oxygen therapy.
Failure to provide sufficient nursing staff consistently to meet resident needs, resulting in delayed call bell responses and residents unable to get out of bed.
Failure to complete annual performance reviews for Certified Nurse Aides (CNAs) for 8 of 8 randomly selected CNAs.
Failure to store, prepare, distribute, and serve food in accordance with professional standards including expired food on trays and in refrigerators, and unclean ice machine with black slime.
Failure to maintain an infection prevention and control program including lack of infection surveillance, outdated water management plan, incomplete staff vaccination education and documentation, and improper implementation of Enhanced Barrier Precautions for 4 residents.
Failure to develop and implement policies and procedures for flu and pneumonia vaccinations including lack of documented education, offering, or declination for 1 of 5 residents (Resident #91).
Failure to educate residents and staff on COVID-19 vaccination, offer vaccine to eligible individuals, and properly document vaccination status for 1 of 5 residents (Resident #91) and 1 of 10 staff (Staff #37).
Report Facts
Residents reviewed for notification of change: 28
Residents reviewed for skin impairments: 4
Residents reviewed for pressure ulcers: 4
Residents reviewed for range of motion and mobility: 3
Residents reviewed for respiratory care: 4
Residents reviewed for COVID vaccine: 5
Staff reviewed for COVID vaccine: 10
Days understaffed: 19
Certified Nurse Aides without performance review: 8
Expired food date: Aug 25, 2024
Resident food expiration date: Aug 13, 2024
Last ice machine cleaning date: Jul 24, 2024
Water Management Plan last review: 201612
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #10 | Registered Nurse | Interviewed regarding failure to notify family of Resident #38's pneumonia. |
| Director of Nursing | Director of Nursing | Interviewed regarding family notification, pressure ulcer care, infection prevention, and staffing. |
| Registered Nurse #26 | Registered Nurse | Interviewed regarding wound care and pressure ulcer interventions for Resident #24. |
| Nurse Practitioner #27 | Nurse Practitioner | Interviewed regarding unstageable wound and pressure ulcer care for Resident #24. |
| Wound Consultant Nurse Practitioner | Nurse Practitioner | Interviewed regarding pressure ulcer prevention measures for Resident #24. |
| Certified Nursing Assistant #28 | Certified Nursing Assistant | Interviewed regarding reporting changes in Resident #24's skin condition. |
| Unit Supervisor Registered Nurse #1 | Registered Nurse Unit Supervisor | Interviewed regarding care plan and hand roll orders for Resident #24. |
| Occupational Therapy Assistant #25 | Occupational Therapy Assistant | Interviewed regarding care plan and issuance of hand rolls for Resident #24. |
| Registered Nurse #8 | Registered Nurse | Interviewed regarding responsibility for hand roll use for Resident #91. |
| Certified Nurse Aide #9 | Certified Nurse Aide | Interviewed regarding responsibility for putting on hand roll for Resident #91. |
| Director of Food Service | Director of Food Service | Interviewed regarding expired food on trays and in refrigerator. |
| Assistant Food Service Director | Assistant Food Service Director | Interviewed regarding food preparation and expired sandwiches. |
| Director of Housekeeping | Director of Housekeeping | Interviewed regarding cleaning of ice machines. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection tracking, vaccination education, and infection control practices. |
| Staffing Coordinator #12 | Staffing Coordinator | Interviewed regarding staffing and performance evaluations. |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding performance evaluations and hand roll use. |
| Certified Nurse Aide #14 | Certified Nurse Aide | Interviewed regarding staffing shortages and resident care. |
| Certified Nurse Aide #29 | Certified Nurse Aide | Interviewed regarding staffing priorities and double shifts. |
| Certified Nurse Aide #6 | Certified Nurse Aide | Interviewed regarding double shifts. |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding responsibility for equipment and care plan updates. |
| Registered Nurse Supervisor #22 | Registered Nurse Supervisor | Interviewed regarding vaccine record tracking. |
| Respiratory Therapist #37 | Respiratory Therapist | Interviewed regarding COVID vaccine status and respiratory care. |
| Certified Nurse Aide #39 | Certified Nurse Aide | Interviewed regarding COVID booster vaccine offer. |
| Certified Nurse Aide #40 | Certified Nurse Aide | Interviewed regarding COVID vaccine series and booster offer. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 30, 2024
Visit Reason
The inspection was conducted as part of the recertification and abbreviated survey from August 26 to August 30, 2024, to assess compliance with regulatory requirements including resident notification and food safety standards.
Findings
The facility failed to promptly notify a resident's representative of a significant change in the resident's condition involving pneumonia and antibiotic treatment. Additionally, the facility did not ensure food safety standards were met, with expired food items found in the kitchen and resident refrigerators, and an ice machine contaminated with black slime.
Deficiencies (4)
Failure to promptly notify a resident's representative of a change in condition involving pneumonia and antibiotic initiation.
Food was stored, prepared, distributed, and served with expired items including peanut butter and jelly sandwiches and egg salad sandwiches.
Resident's personal food was stored beyond the facility's 3-day limit in the resident pantry refrigerator.
The first floor resident ice machine was not clean and had black slime inside, posing contamination risk.
Report Facts
Residents reviewed for notification: 28
Expired peanut butter and jelly sandwiches: 5
Expired egg salad sandwiches: 1
Resident food items beyond 3-day limit: 2
Last ice machine cleaning date: Jul 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #10 | Registered Nurse | Interviewed regarding family notification policy and incident |
| Director of Nursing | Director of Nursing | Interviewed regarding responsibility for family notification |
| Assistant Food Service Director | Assistant Food Service Director | Interviewed regarding food preparation and expired sandwiches |
| Director of Food Service | Director of Food Service | Interviewed regarding food safety and expired sandwiches |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding resident food storage policy |
| Director of Housekeeping | Director of Housekeeping | Interviewed regarding ice machine cleaning and contamination |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 28, 2023
Visit Reason
One Level 2 deficiency related to accident hazards, supervision, and devices. Corrected by January 19, 2024.
Findings
One Level 2 deficiency related to accident hazards, supervision, and devices. Corrected by January 19, 2024.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 28, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to investigate the facility's compliance with accident prevention and supervision requirements following a resident fall incident.
Complaint Details
The visit was complaint-related, investigating a fall incident involving Resident #1. The complaint was substantiated as the facility failed to follow the resident's care plan requiring two-person assistance, resulting in injury.
Findings
The facility failed to ensure adequate supervision and accident hazard prevention for Resident #1, who required two-person assistance but was cared for by a single CNA, resulting in the resident falling out of bed and sustaining fractures. Staff failed to follow the resident's plan of care, leading to disciplinary action and reeducation.
Deficiencies (1)
Failure to provide adequate supervision and maintain a safe environment to prevent accidents for Resident #1 requiring two-person assistance, resulting in a fall and fracture.
Report Facts
Fall Risk Assessment score: 16
Brief Interview for Mental Status (BIMS) score: 12
Deficiency count: 1
Suspension duration: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nursing Assistant | Named in deficiency for providing care without required assistance leading to resident fall |
| LPN #1 | Licensed Practical Nurse | Responded to resident fall and provided initial assessment |
| RN #1 | Registered Nurse | Interviewed regarding protocol adherence for two-person assist residents |
| Administrator | Interviewed regarding staff expectations and disciplinary actions | |
| Director of Nursing | DON | Interviewed regarding staff training, competency, and disciplinary actions |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Aug 14, 2023
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network. Not corrected at time of report.
Findings
One Level 2 deficiency related to reporting to the national health safety network. Not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 9, 2022
Visit Reason
One Level 2 deficiency related to notification of changes (injury/decline/room, etc.). Corrected by December 22, 2022.
Findings
One Level 2 deficiency related to notification of changes (injury/decline/room, etc.). Corrected by December 22, 2022.
Deficiencies (1)
Notify of changes (injury/decline/room, etc.)
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Sep 14, 2022
Visit Reason
One Level 2 deficiency related to residents being free of significant medication errors. Corrected by October 7, 2022.
Findings
One Level 2 deficiency related to residents being free of significant medication errors. Corrected by October 7, 2022.
Deficiencies (1)
Residents are free of significant med errors
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Feb 24, 2022
Visit Reason
Two Level 2 deficiencies related to notification of changes and treatment/services to prevent/heal pressure ulcers. Corrected by March 31, 2022.
Findings
Two Level 2 deficiencies related to notification of changes and treatment/services to prevent/heal pressure ulcers. Corrected by March 31, 2022.
Deficiencies (2)
Notify of changes (injury/decline/room, etc.)
Treatment/svcs to prevent/heal pressure ulcer
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 13, 2021
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network. Not corrected at time of report.
Findings
One Level 2 deficiency related to reporting to the national health safety network. Not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 18, 2021
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in maintaining resident dignity and privacy during care and medication administration, ensuring scheduled showers were provided, administering bowel medications according to protocol, following proper infection control practices during wound care, and maintaining a pest control program.
Deficiencies (5)
Failure to maintain resident dignity and privacy during wound care and medication pass.
Failure to provide scheduled showers as required and document refusals appropriately.
Failure to administer bowel medication according to facility protocol and inconsistent bowel movement documentation.
Failure to follow proper hand hygiene and gloving technique during wound care, leading to cross contamination risks.
Failure to maintain pest control program resulting in presence of gnats in kitchen and resident areas.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Resident floors: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in wound care infection control and dignity/privacy deficiencies |
| CNA #1 | Certified Nursing Assistant | Named in wound care infection control and dignity/privacy deficiencies |
| Medication Nurse #1 | Named in medication administration privacy deficiency | |
| Director of Nursing | DON | Interviewed regarding privacy and dignity monitoring |
| RN #3 | Registered Nurse | Named in shower documentation and bowel medication deficiencies |
| CNA #4 | Certified Nursing Assistant | Named in shower refusal and documentation deficiency |
| RN #2 | Registered Nurse | Named in bowel documentation and monitoring deficiency |
| RN #3 | Registered Nurse | Named in infection control deficiency during wound care |
| CNA #3 | Certified Nursing Assistant | Named in infection control deficiency during wound care |
| RN #2 | Registered Nurse | Named in infection control deficiency during wound care |
| Dietary Director | Named in pest control deficiency |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 22, 2019
Visit Reason
The inspection was conducted as part of the most recent recertification survey to assess compliance with care plan implementation and dialysis treatment procedures.
Findings
The facility failed to ensure consistent implementation of the care plan for pre-dialysis assessments for one resident and did not address post-dialysis assessments in the care plan. Documentation of pre and post dialysis assessments was inconsistent, and the Unit Manager acknowledged missed documentation despite performing assessments.
Deficiencies (1)
Failure to implement a complete care plan addressing pre and post dialysis assessments consistently for Resident #47 and for activities of daily living for Resident #11.
Report Facts
Dialysis days per week: 3
Pre-dialysis assessment dates documented: 4
Post-dialysis assessment dates documented: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager/Registered Nurse | Interviewed regarding lack of consistent pre and post dialysis assessments and documentation |
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