Inspection Reports for
River View Rehabilitation and Nursing Care Center
510 Fifth Avenue, Owego, NY, 13827
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jul 3, 2025
Visit Reason
Inspection identified a Level 3 deficiency related to abuse and neglect resulting in actual harm; deficiency was corrected on the same day.
Findings
Inspection identified a Level 3 deficiency related to abuse and neglect resulting in actual harm; deficiency was corrected on the same day.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 3, 2025
Visit Reason
The abbreviated survey was conducted to investigate allegations of abuse involving a Registered Nurse Supervisor and a resident during a transfer on 06/08/2025.
Complaint Details
The investigation was complaint-related, triggered by allegations from Resident #1 that Registered Nurse Supervisor #1 grabbed them by the neck during a transfer, causing pain and a scratch. The resident wanted to press charges and called the police. The facility and police conducted investigations. The nurse was suspended and resigned. The resident exhibited fear and post-traumatic stress symptoms following the incident.
Findings
The facility failed to ensure a resident's right to be free from abuse when a Registered Nurse Supervisor held a resident by the neck during a transfer, causing physical pain and mental anguish. The nurse was suspended and later resigned. The facility initiated an investigation, notified police, and provided staff education on abuse.
Deficiencies (1)
F 0600: The facility did not protect a resident from abuse when a Registered Nurse Supervisor held the resident by the neck during a transfer, causing physical pain and a scratch. The nurse was suspended and resigned.
Report Facts
Residents reviewed: 3
Staff education completion: 80
Days to corrective action completion: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Named in abuse finding for holding resident by the neck and verbal threats |
| Certified Nurse Aide #3 | Certified Nurse Aide | Witnessed and reported aggressive behavior by Registered Nurse Supervisor #1 |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Alerted to resident's injury and interviewed regarding incident |
| Registered Nurse Supervisor #7 | Registered Nurse Supervisor | Assessed resident after incident and corroborated injury |
| Director of Social Services | Director of Social Services | Conducted follow-up with resident and participated in investigation |
| Administrator | Administrator | Led investigation and ruled out abuse based on staff statements |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Nov 15, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with nutritional, food safety, and meal service standards at River View Rehabilitation and Nursing Care Center.
Findings
The facility failed to ensure that planned menus were followed, resulting in residents not receiving preferred food items. Food and drink served were often not palatable, attractive, or at safe temperatures. The kitchen environment was unclean, food was improperly stored and cooled, and proper hand hygiene was not consistently practiced during meal service.
Deficiencies (3)
F 0803: The facility did not ensure planned menus were followed for 3 residents, resulting in residents not receiving preferred food items as per individualized meal tickets.
F 0804: The facility did not ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures for multiple residents and meal trays observed.
F 0812: The facility did not ensure food was procured, stored, prepared, distributed, and served according to professional food service safety standards, with unclean kitchen areas, improper food cooling, inadequate food storage temperatures, and lack of proper hand hygiene.
Report Facts
Residents affected: 3
Anonymous residents: 11
Meal trays observed: 3
Temperature measurements: 110.8
Temperature measurements: 129.6
Temperature measurements: 46.9
Temperature measurements: 49.8
Temperature measurements: 42.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Overseeing kitchen operations after Director of Dietary left; involved in interviews and observations. | |
| Certified Nurse Aide #14 | Reported on coffee availability and resident complaints about food temperature. | |
| Dietary Aide #16 | Printed meal tickets, production sheets, ordered food, and assisted with paperwork. | |
| Licensed Practical Nurse Unit Manager #13 | Described coffee service procedures. | |
| Registered Dietitian #17 | Interviewed about kitchen operations and meal ticket accuracy. | |
| Maintenance Director #20 | Reported on sink drainage issues. | |
| Dietary Aide #18 | Observed not changing gloves or performing hand hygiene during meal service. | |
| Cook on duty | Responsible for checking refrigerator temperatures. |
Inspection Report
Annual Inspection
Capacity: 77
Deficiencies: 7
Date: Nov 15, 2024
Visit Reason
The inspection was a recertification survey conducted from 11/12/2024 to 11/15/2024 to assess compliance with federal and state regulations for nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, lack of resident consent for monitoring devices, failure to follow planned menus, serving food at improper temperatures, unsanitary kitchen conditions, incomplete binding arbitration agreements, and unsafe, unclean resident and medication room environments.
Deficiencies (7)
F 0577: The facility did not ensure the most recent survey results were posted in a readily accessible place for residents and the public, and did not post notice of availability of survey results in prominent areas.
F 0583: The facility did not obtain resident or representative consent for individual monitoring devices transmitting personal health information to a third party for 50 of 77 residents.
F 0803: The facility did not ensure planned menus were followed for 3 residents; residents did not receive preferred food items as planned per individualized meal tickets.
F 0804: The facility did not ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures for multiple residents and meals observed.
F 0812: The facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards; kitchen was unclean, food cooling and storage temperatures were unsafe, and hand hygiene was inadequate.
F 0847: The facility did not ensure the binding arbitration agreement was explained and completed properly for 1 resident; the agreement was incomplete and not followed up on for completeness.
F 0921: The facility did not ensure a safe, functional, sanitary, and comfortable environment in one resident room and one medication room; resident room had unclean floors and medication room had unrepaired water damage.
Report Facts
Residents reviewed: 77
Residents affected by monitoring device consent deficiency: 50
Devices installed: 77
Devices connected and assigned: 50
Devices disconnected and assigned: 27
Current utilization rate: 65
Residents reviewed for menu compliance: 3
Anonymous residents at Resident Council: 11
Residents affected by food temperature and palatability issues: 11
Residents affected by arbitration agreement deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager #27 | Business Office Manager | Named in binding arbitration agreement deficiency and interview about agreement process |
| Administrator | Facility Administrator | Named in multiple interviews regarding survey results posting, monitoring devices, kitchen and food service, and arbitration agreement |
| Certified Nurse Aide #4 | Certified Nurse Aide | Interviewed about knowledge of survey results posting |
| Certified Nurse Aide #5 | Certified Nurse Aide | Interviewed about survey results discussion with residents |
| Certified Nurse Aide #24 | Certified Nurse Aide | Interviewed about monitoring devices installation |
| Licensed Practical Nurse Unit Manager #13 | Licensed Practical Nurse Unit Manager | Interviewed about monitoring devices and medication room condition |
| Dietary Aide #16 | Dietary Aide | Interviewed about meal ticket process and kitchen oversight |
| Registered Dietitian #17 | Registered Dietitian | Interviewed about menu planning and kitchen food supply |
| Corporate Director of Facilities | Corporate Director of Facilities | Interviewed about kitchen and medication room conditions |
| Maintenance Director | Maintenance Director | Interviewed about water damage repair status |
| Housekeeper #22 | Housekeeper | Interviewed about resident room cleaning |
| Housekeeper #23 | Housekeeper | Interviewed about resident room cleaning |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 5
Date: Oct 14, 2022
Visit Reason
Inspection identified multiple Level 2 deficiencies related to nutrition/hydration status and several Life Safety Code issues including doors, hazardous areas, maintenance, and stairways; all deficiencies were corrected by November 22, 2022.
Findings
Inspection identified multiple Level 2 deficiencies related to nutrition/hydration status and several Life Safety Code issues including doors, hazardous areas, maintenance, and stairways; all deficiencies were corrected by November 22, 2022.
Deficiencies (5)
Nutrition/hydration status maintenance
Doors with self-closing devices
Hazardous areas - enclosure
Maintenance, inspection & testing - doors
Stairways and smokeproof enclosures
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 14, 2022
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory standards for River View Rehabilitation and Nursing Care Center.
Findings
The facility failed to ensure adequate nutritional status for one resident with significant unaddressed weight loss and failed to properly label and store medications, including expired stock medications and an opened multi-dose vial beyond 30 days.
Deficiencies (2)
F 0692: The facility failed to ensure residents maintained acceptable nutritional status, specifically Resident #33 had significant weight loss that was not reassessed or addressed by clinical nutrition staff.
F 0761: The facility failed to ensure drugs and biologicals were labeled and stored properly, with expired medications found in medication carts and storage rooms, and an opened multi-dose vial in the medication refrigerator beyond 30 days.
Report Facts
Weight loss percentage: 5.5
Weight loss percentage: 7.5
Expiration dates: 5
Multi-dose vial open duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PA #8 | Physician Assistant | Documented resident's appetite and was involved in weight discussions. |
| RD #9 | Registered Dietitian | Responsible for nutrition assessments and recommendations for Resident #33. |
| LPN Unit Manager #4 | Licensed Practical Nurse Unit Manager | Documented resident weights, medication cart checks, and provided interviews regarding deficiencies. |
| LPN #3 | Licensed Practical Nurse | Observed expired medications during medication storage observation. |
| LPN Unit Manager #5 | Licensed Practical Nurse Unit Manager | Observed opened multi-dose vial in medication refrigerator. |
| Director of Nursing | Director of Nursing | Provided information on weight monitoring and medication expiration responsibilities. |
| Director of Purchasing | Director of Purchasing | Responsible for restocking medication rooms and checking for expired medications. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Mar 4, 2020
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for River View Rehabilitation and Nursing Care Center.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, maintaining a clean and homelike environment, comprehensive care planning, proper use of assistive devices, food palatability and temperature, and infection prevention practices.
Deficiencies (6)
F 0550: The facility failed to ensure residents' dignity and privacy as staff were observed having personal conversations during meals and discussing private resident information loudly at the nursing station.
F 0584: Resident #14's room was not maintained in a clean and homelike manner as a basin containing emesis was left on the garbage can for three days.
F 0656: Resident #12 did not have hearing aids placed for two days and hearing aid use was not documented in the care plan or medication records.
F 0688: Resident #21 was observed without a palm guard as care planned to prevent contractures, despite care plan instructions and therapy recommendations.
F 0804: Food served to residents during breakfast, lunch, and dinner was at unsafe and unpalatable temperatures, with hot foods served below 140°F and cold foods above 40°F.
F 0880: Licensed practical nurses were observed not performing hand hygiene during medication administration, increasing risk of infection transmission.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 4
Food temperatures: 122
Food temperatures: 110
Food temperatures: 66
Food temperatures: 110
Food temperatures: 129
Food temperatures: 47
Food temperatures: 131
Food temperatures: 132
Food temperatures: 111
Food temperatures: 46
Food temperatures: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Named in dignity deficiency for personal conversations during meals |
| RN Unit Manager #4 | Registered Nurse Unit Manager | Interviewed regarding dignity and hearing aid care plan deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding dignity and privacy expectations |
| MDS Coordinator | Minimum Data Set Coordinator | Observed discussing resident information loudly at nursing station |
| ADON | Assistant Director of Nursing | Interviewed regarding privacy and infection control |
| Housekeeper #8 | Housekeeper | Interviewed regarding basin with emesis in resident room |
| CNA #9 | Certified Nurse Aide | Interviewed regarding basin with emesis and resident care |
| LPN Unit Manager #10 | Licensed Practical Nurse Unit Manager | Interviewed regarding homelike environment and basin care |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding palm guard use and resident care |
| CNA #1 | Certified Nurse Aide | Interviewed regarding palm guard use for Resident #21 |
| Director of Therapy | Director of Therapy | Interviewed regarding palm guard evaluation and use |
| Food Service Director | Food Service Director | Interviewed regarding food temperature standards |
| LPN #11 | Licensed Practical Nurse | Observed and interviewed regarding hand hygiene during medication administration |
| LPN #12 | Licensed Practical Nurse | Observed and interviewed regarding hand hygiene during medication administration |
| ADON/Infection Control RN #7 | Assistant Director of Nursing/Infection Control RN | Interviewed regarding hand hygiene training and expectations |
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