Inspection Reports for
River Ridge Living Center
100 Sandy Drive, Amsterdam, NY, 12010
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
200% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Mar 18, 2025
Visit Reason
The inspection was a recertification and abbreviated survey to assess compliance with regulatory requirements including resident care, abuse prevention, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to prevent resident abuse and neglect, delayed reporting of abuse allegations, inadequate investigation of abuse claims, failure to prevent accidents and elopement, improper medication storage, failure to provide ordered respiratory care, unpalatable and improperly served food, and lapses in infection prevention and control practices including wound care and isolation precautions.
Deficiencies (7)
F 0600: Resident #14 was not protected from abuse and neglect when a Certified Nurse Aide provided care alone instead of two-person assist, resulting in a fall with injury and missing floor mats as care planned.
F 0609: The facility failed to timely report suspected abuse for Residents #14 and #32 to the New York State Department of Health within the required 2-hour timeframe.
F 0610: Resident #32's allegation of abuse was not thoroughly investigated; no timely investigation or report was made despite resident complaints and staff awareness.
F 0689: The facility failed to prevent accidents and provide adequate supervision for Resident #58 who eloped and Resident #74 who had prescription cream improperly stored in their room.
F 0695: Residents #24, 32, 34, and 61 did not consistently receive ordered continuous oxygen therapy; oxygen was off or set incorrectly during observations.
F 0804: Residents #19 and #32 received food that was cold, unappetizing, and did not match their meal tickets; resident complaints about food quality were documented.
F 0880: Infection prevention and control deficiencies included improper wound care technique by Licensed Practical Nurses for Residents #32 and #47, failure to maintain isolation precautions by leaving Covid isolation room doors open, and lack of a current water management plan for Legionella.
Report Facts
Residents reviewed for abuse: 7
Residents reviewed for oxygen administration: 5
Residents reviewed for palatable food: 11
Residents reviewed for infection control: 4
Date of incident for Resident #14 fall: 2025
Date of report for Resident #14 fall: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in wound care infection control deficiency for Resident #32 |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding Resident #14 fall and oxygen therapy |
| Certified Nurse Aide #11 | Certified Nurse Aide | Reported abuse allegation for Resident #32 |
| Director of Nursing #1 | Director of Nursing | Interviewed about Resident #14 fall and abuse reporting |
| Administrator #1 | Administrator | Interviewed about abuse reporting and food service issues |
| Registered Dietician #1 | Registered Dietician | Interviewed about food substitutions and resident nutrition |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Named in wound care infection control deficiency for Resident #47 |
Inspection Report
Annual Inspection
Census: 109
Capacity: 120
Deficiencies: 21
Date: Mar 18, 2025
Visit Reason
Recertification and abbreviated survey to assess compliance with state and federal regulations for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, medication administration, care planning, infection control, staffing, food service, and environmental safety. Several residents experienced lapses in care such as lack of adaptive utensils, delayed assistance, improper medication handling, and inadequate oxygen therapy. The facility also had issues with pest control, food storage, and maintenance.
Deficiencies (21)
F 0550: The facility failed to ensure residents were treated with dignity and respect, including proper use of adaptive utensils, timely assistance, and knocking before entering rooms.
F 0554: The facility did not ensure residents were properly assessed for safe self-administration of medications, specifically Resident #16 self-administering nebulized medication without assessment or physician order.
F 0561: The facility failed to promote resident self-determination, including respecting Resident #32's choice of C-PAP timing and Resident #34's choice to return to bed after dialysis.
F 0584: Resident #17's personal clothing was not returned timely and was missing; the facility did not ensure proper laundry handling and grievance awareness.
F 0585: The facility did not ensure residents were aware of the grievance process; grievance forms were not readily available and residents were unaware how to file grievances.
F 0600: Resident #14 was injured after a fall due to staff providing care alone when two-person assist was required and floor mats were not in place as care planned.
F 0609: The facility failed to timely report alleged abuse incidents involving Residents #14 and #32 to the New York State Department of Health.
F 0656: The facility did not develop and implement comprehensive person-centered care plans for Residents #24, #32, and #73, including failure to address oxygen therapy, abuse risk, and dialysis care.
F 0657: The facility did not review and revise care plans for Residents #32 and #68 based on changes in condition or resident refusals, including oxygen therapy and positioning devices.
F 0689: The facility failed to provide adequate supervision to prevent elopement for Resident #58 and improperly stored resident medications and personal items in Resident #74's room.
F 0692: Resident #51's weight was not monitored monthly as care planned, quarterly dietary assessments were not completed, and Resident #64 lacked a nutrition care plan and scheduled weights.
F 0695: Residents #24, #32, #34, and #61 did not consistently receive supplemental oxygen as ordered by physicians.
F 0725: Staffing levels were below the facility's assessed minimum requirements on multiple occasions, resulting in delayed care and resident complaints.
F 0756: The facility's policy for monthly drug regimen review lacked defined time frames for pharmacist notification, physician response, and nursing follow-up.
F 0761: Multiple medication carts and medication room contained unlabeled or expired medications, discontinued drugs, and improperly stored items including insulin pens without open dates and leftover tube feed.
F 0804: Residents #19 and #32 reported food was cold, unappetizing, and did not match meal tickets; kitchen staff acknowledged substitutions and shortages.
F 0810: Resident #38 did not consistently receive adaptive eating utensils as ordered and required; kitchen staff reported shortages and difficulty replacing items.
F 0812: The main kitchen and two resident kitchenettes were unclean with food debris, damaged walls, and lacked proper sanitizing test equipment.
F 0813: Food brought by family or visitors was not properly labeled with resident name, date received, and discard date in the resident unit kitchenette.
F 0880: Licensed Practical Nurses did not maintain proper infection control during wound dressing changes for Residents #32 and #47; isolation room doors for Covid-positive residents were left open; facility lacked a current Legionella water management plan.
F 0925: The facility had a persistent fly infestation on the C-Wing, with flies observed in corridors, resident rooms, and during meal service; pest control measures were insufficient.
Report Facts
Medication error rate: 7.41
Resident census: 109
Total licensed capacity: 120
Weight loss percent: 8.06
Oxygen liters ordered: 4
Oxygen liters observed: 3.5
Medication counts: 8
Medication counts: 3
Medication counts: 3
Medication counts: 3
Medication counts: 1
Tube feed volume: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in wound care infection control deficiency and oxygen therapy observation |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Named in medication administration and wound care deficiencies |
| Registered Nurse #3 | Registered Nurse | Named in food service and oxygen therapy deficiencies |
| Director of Nursing #1 | Director of Nursing | Named in multiple interviews regarding deficiencies and policies |
| Kitchen Supervisor #1 | Kitchen Supervisor | Named in food service and adaptive utensils deficiencies |
| Certified Nurse Aide #9 | Certified Nurse Aide | Named in adaptive utensils deficiency |
| Certified Nurse Aide #11 | Certified Nurse Aide | Named in abuse allegation reporting |
| Registered Dietitian #1 | Registered Dietitian | Named in nutrition assessment and food service deficiencies |
| Administrator #1 | Facility Administrator | Named in multiple interviews regarding deficiencies and pest control |
| Consultant #1 | Consultant | Named in water management plan interview |
Inspection Report
Covid-19 Survey
Capacity: 60
Deficiencies: 1
Date: Mar 11, 2024
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm but potential for minor harm.
Findings
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm but potential for minor harm.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Covid-19 Survey
Capacity: 60
Deficiencies: 1
Date: Feb 20, 2024
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm but potential for minor harm.
Findings
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm but potential for minor harm.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Covid-19 Survey
Capacity: 60
Deficiencies: 1
Date: Feb 12, 2024
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm but potential for minor harm.
Findings
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm but potential for minor harm.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Covid-19 Survey
Capacity: 60
Deficiencies: 1
Date: Feb 6, 2024
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm but potential for minor harm.
Findings
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm but potential for minor harm.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Covid-19 Survey
Capacity: 60
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm but potential for minor harm.
Findings
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm but potential for minor harm.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Survey
Capacity: 60
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
One Level 2 deficiency for accident hazards/supervision/devices, isolated scope, corrected as of June 13, 2023.
Findings
One Level 2 deficiency for accident hazards/supervision/devices, isolated scope, corrected as of June 13, 2023.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety regulations, specifically regarding supervision to prevent resident accidents and elopement risks.
Findings
The facility failed to ensure adequate supervision to prevent accidents, as Resident #1, identified as an elopement risk, exited the facility through an alarmed door without staff awareness. The investigation revealed possible alarm system failures and staffing issues, leading to the resident being found outside the facility approximately half a mile away.
Deficiencies (1)
F 0689: The facility failed to ensure each resident received adequate supervision to prevent accidents. Resident #1 exited the building through an alarmed door without staff awareness, despite policies requiring constant monitoring and alarm response.
Report Facts
Residents with wanderguard bracelets: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Documented finding Resident #1 outside the facility and noted alarm was not heard |
| RN #1 | Registered Nurse | Last to see Resident #1 before elopement and commented on lack of alarm awareness |
| LPN #1 | Licensed Practical Nurse | Reported multiple elopement attempts by Resident #1 and use of wanderguard |
| LPN #3 | Licensed Practical Nurse | Recalled Resident #1 exit seeking and location found approximately one mile away |
| CNA #1 | Certified Nursing Aide | Described staff responsibilities when alarms activate |
| RN #3 | Registered Nurse | Reviewed video footage and noted inability to identify alarm activation |
| Maintenance Director | Described facility alarm system and camera coverage |
Inspection Report
Complaint Survey
Capacity: 60
Deficiencies: 3
Date: Feb 6, 2023
Visit Reason
Three Level 2 deficiencies related to investigation/prevention of violations, notification of changes, and quality of care; all isolated scope and corrected by March 7, 2023.
Findings
Three Level 2 deficiencies related to investigation/prevention of violations, notification of changes, and quality of care; all isolated scope and corrected by March 7, 2023.
Deficiencies (3)
Investigate/prevent/correct alleged violation
Notify of changes (injury/decline/room, etc.)
Quality of care
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jan 10, 2023
Visit Reason
The inspection was a recertification survey conducted from January 3, 2023 through January 10, 2023 to assess compliance with regulatory standards for River Ridge Living Center.
Findings
The facility was found deficient in multiple areas including failure to provide written notice of bed hold policy to residents upon hospital transfer, inadequate wound care for a resident with Stage 4 pressure ulcers, failure to consistently provide resident food preferences and adaptive eating equipment, food service safety violations including dishwashing machine malfunction and unclean kitchen equipment, and improper labeling and storage of foods brought in by visitors.
Deficiencies (6)
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. The facility did not provide written notice of the bed hold policy for 2 residents upon hospital transfer.
Provide appropriate pressure ulcer care and prevent new ulcers from developing. The facility did not ensure wound care treatments for a resident’s Stage 4 sacral wounds were provided as ordered by the physician.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences. The facility did not consistently provide food preferences, including correct milk portions, for a resident on multiple occasions.
Provide special eating equipment and utensils for residents who need them and appropriate assistance. The facility did not provide adaptive eating utensils as documented for a resident on all meals observed.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. The dishwashing machine was not operating within manufacturer specifications and kitchen equipment and floors required cleaning and repair.
Have a policy regarding use and storage of foods brought to residents by family and other visitors. The facility did not ensure foods brought in were properly labeled and discarded per policy in three kitchenettes.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in wound care deficiency for not following physician's wound care orders |
| LPNUM #4 | Licensed Practical Nurse Unit Manager | Supervised wound care and confirmed wound care deficiency |
| Social Worker #6 | Social Worker | Interviewed regarding bed hold notice documentation |
| Certified Nurse Aid #4 | Certified Nurse Aid | Reported complaints about missing meal items and adaptive equipment |
| Director of Nursing | Director of Nursing | Provided statements regarding wound care and meal tray responsibilities |
| Interim Food Service Director | Interim Food Service Director | Provided statements regarding meal tray accuracy and dishwashing machine issues |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Provided statements regarding meal tray and adaptive equipment checks |
Inspection Report
Complaint Survey
Capacity: 60
Deficiencies: 11
Date: Jan 10, 2023
Visit Reason
Multiple Level 2 deficiencies in standard health and life safety code categories including assistive devices, food sanitation, bed hold policy, personal food policy, resident allergies, pressure ulcer treatment, electrical systems, EP testing and training, smoke barriers, and vertical openings; corrected mostly by February-March 2023.
Findings
Multiple Level 2 deficiencies in standard health and life safety code categories including assistive devices, food sanitation, bed hold policy, personal food policy, resident allergies, pressure ulcer treatment, electrical systems, EP testing and training, smoke barriers, and vertical openings; corrected mostly by February-March 2023.
Deficiencies (11)
Assistive devices - eating equipment/utensils
Food procurement,store/prepare/serve-sanitary
Notice of bed hold policy before/upon trnsfr
Personal food policy
Resident allergies, preferences, substitutes
Treatment/svcs to prevent/heal pressure ulcer
Electrical systems - essential electric syste
Ep testing requirements
Ep training program
Subdivision of building spaces - smoke barrie
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 25, 2020
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory standards for nursing home care, including abuse reporting, treatment and care, medication regimen review, food safety, waste disposal, and medical record documentation.
Findings
The facility was found deficient in timely reporting of alleged abuse, monitoring and documentation of treatments and medications, medication regimen review documentation, food service cleanliness, garbage disposal, and accurate medical record keeping. Deficiencies involved minimal harm with few residents affected.
Deficiencies (6)
F 0609: The facility failed to report an alleged abuse incident involving a resident restrained to a wheelchair within the required 2-hour timeframe to the administrator and other officials.
F 0684: The facility did not provide monitoring for effectiveness of as-needed medication for one resident and failed to assist another resident with a physical therapy home exercise plan to prevent functional decline.
F 0756: The facility did not ensure attending physicians documented review and rationale for pharmacist-identified medication irregularities for three residents.
F 0812: The facility did not store, prepare, distribute, or serve food in accordance with professional standards; kitchen equipment, floors, and walls were soiled with food particles, dirt, or grime.
F 0814: The facility failed to properly dispose of garbage; the trash compactor was leaking waste and the area was heavily soiled.
F 0842: The facility did not maintain accurate and complete medical records for two residents, including inaccurate documentation of bed transfers, incomplete treatment documentation, and failure to document oxygen tubing changes as ordered.
Report Facts
Medication administrations: 14
Medication regimen review dates missing physician documentation: 3
Residents reviewed for unnecessary medications: 5
Residents reviewed for treatment and care: 18
Residents affected by deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported seeing resident restrained to wheelchair and notified Director of Nursing via text |
| Director of Nursing | Director of Nursing | Received delayed notification of abuse incident and acknowledged failure to report to Administrator promptly |
| Administrator | Facility Administrator | Initiated investigation after delayed notification of abuse incident |
| LPN #7 | Licensed Practical Nurse | Entered medication order for Lomotil but failed to include monitoring in system |
| Registered Nurse #2 | Registered Nurse | Stated PRN medications should be monitored for effectiveness and documented |
| Director of Rehab Services | Director of Rehabilitation Services | Stated expectation that PT would update care plan for discharge recommendations |
| Director of Food Service | Director of Food Service | Acknowledged food service cleaning deficiencies and planned corrective actions |
| Environmental Services Manager | Environmental Services Manager | Reported plans to replace leaking trash compactor and clean area |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Admitted to inaccurate documentation of resident transfers out of bed |
| Registered Nurse Unit Manager #2 | Registered Nurse Unit Manager | Stated expectation for accurate and timely documentation of care |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Noted oxygen tubing should be changed weekly and not signed if treatment not done |
Viewing
Loading inspection reports...
