SEO_DESCRIPTION: Riverfront Rehabilitation in Pennsauken failed to track expired medications properly, stored medical supplies unsafely, and had infection control lapses.
OG_TITLE: NJ Nursing Home Failed to Monitor Expired Meds Despite Ongoing Safety Concerns
OG_DESCRIPTION: Federal inspectors found Riverfront Rehabilitation couldn't track expired medications on medication carts despite identifying this as a "major concern" in quality improvement plans for months.
FB_POST: NJ nursing home couldn't track expired meds on carts despite months of safety plans - federal inspectors cite facility
ARTICLE: PENNSAUKEN, NJ - Federal inspectors cited Riverfront Rehabilitation and Healthcare Center for failing to implement basic medication safety protocols, despite the facility's own quality improvement plans identifying expired medications as a "major concern" for months.
Quality Improvement Plan Failures
The August 2024 inspection revealed significant gaps in the facility's Quality Assessment and Performance Improvement (QAPI) program. Inspectors found that despite creating action plans in February and April 2024 to address expired medications, the facility collected no data to verify whether their safety measures were working.
The facility's QAPI policy required nursing administration to "utilize facility data to identify opportunities to improve systems and care," including medication safety monitoring. However, when inspectors requested documentation of the three-times-weekly medication cart checks outlined in the improvement plans, facility staff admitted they had no records.
The Director of Nursing told inspectors they "do not have any data collected for the expired medication QAPI plan" and acknowledged "the QAPI plan did not work."
Medication Safety Protocols Ignored
Both February and April 2024 quality improvement plans identified the same root causes: expired medications found on carts and in medication rooms during consultant pharmacist inspections, and nursing staff failing to check carts for expired medications. The plans required Licensed Practical Nurses to receive education about checking carts for expired medications three times per week.
The April plan claimed 77% compliance with medication labeling, up from March levels. However, when inspectors asked where this data came from, the Director of Nursing could only speculate that "it's possible that the data reported came from the monthly consultant pharmacist visit."
Expired medications present serious health risks to residents. Using expired drugs can result in reduced effectiveness, potentially leaving infections untreated or pain unmanaged. In some cases, chemical breakdown of expired medications can create toxic compounds that may harm residents.
Infection Control Violations
Inspectors also documented multiple infection prevention and control failures throughout the facility. In the Pavilion Three medication storage room, staff had improperly stored sterile medical supplies beneath a handwashing sink, including gauze pads, wound dressings, and enema kits.
The Licensed Practical Nurse Unit Manager acknowledged she "never checked under the sink" and recognized that contamination was the "issue with the items being stored under the sink." The Central Supply Director confirmed that facility policy prohibited storing anything under sinks due to infection control concerns.
Compromised Medical Supplies
In Pavilion Two's medication room, inspectors found an opened one-liter bag of intravenous sodium chloride solution that had been returned to storage. The Registered Nurse Unit Manager acknowledged that "the effectiveness of the medication could be compromised."
Storing opened IV fluids violates basic sterility requirements. Once the sterile packaging is breached, the solution becomes vulnerable to bacterial contamination. Using contaminated IV solutions can introduce dangerous pathogens directly into residents' bloodstreams, potentially causing life-threatening infections.
Personal Protective Equipment Failures
The inspection revealed that laundry staff were not following required infection control protocols when handling potentially contaminated materials. Inspectors observed a worker wearing a surgical mask below her nose while emptying soiled laundry, and she was not wearing the required protective apron.
When questioned, the worker stated she was required to wear "gloves, mask, and cover (apron) to keep clothes clean," but admitted "I wasn't wearing the cover when the surveyor came in."
The worker then removed her protective equipment improperly, draping the apron over dirty laundry bins and failing to perform hand hygiene after removing gloves. These practices can spread infectious agents throughout the facility.
Administrative Knowledge Gaps
The inspection revealed concerning gaps in staff knowledge about basic safety protocols. The Infection Preventionist admitted he "did not know the facility policy for storing items beneath the handwashing sink" and was "not familiar with the laundry policy regarding soiled linens."
The Director of Environmental Services and Laundry contradicted other staff statements, saying workers "are supposed to be covered up with gown, gloves, and mask" and use "yellow gowns" rather than aprons, adding "I have never seen anybody wear the apron."
Medical Safety Standards
Federal regulations require nursing homes to maintain comprehensive quality assurance programs that systematically monitor and improve care delivery. Medication management represents a critical component of resident safety, as elderly residents typically take multiple medications that require careful monitoring for effectiveness and potential interactions.
Proper infection control protocols are essential in congregate care settings where vulnerable residents face elevated risks from healthcare-associated infections. The Centers for Disease Control and Prevention estimates that nursing home residents experience infection rates significantly higher than community-dwelling elderly adults.
Regulatory Response
The Centers for Medicare & Medicaid Services classified these violations as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the systemic nature of the quality improvement failures suggests broader concerns about the facility's ability to monitor and maintain safety standards.
The violations occurred despite the facility's own recognition that expired medications represented a "major concern" requiring ongoing attention. The inability to implement basic data collection for safety monitoring raises questions about the effectiveness of the facility's oversight systems.
Riverfront Rehabilitation's 2024 violations highlight the critical importance of systematic quality improvement programs in nursing home operations. When facilities fail to collect and analyze safety data, they cannot verify whether their improvement efforts are protecting residents or simply creating the appearance of compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverfront Rehabilitation and Healthcare Center from 2024-08-14 including all violations, facility responses, and corrective action plans.
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