River Front Rehabilitation And Healthcare Center
RIVER FRONT REHABILITATION AND HEALTHCARE CENTER in PENNSAUKEN, NJ — inspection on August 14, 2024.
Found 15 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The surveyor interviewed Licensed Practical Nurse (LPN #2).
The surveyor asked LPN #2 how a non-ambulatory resident should be properly transported. LPN #2 responded by stating that she was sorry.
A review of the Electroinic Medical Record on 08/06/2024 at 09:26 AM, revealed the following: A review of the admission Record revealed that Resident #27 was admitted to the facility with the following but not limited to diagnoses: Contracture (unspecified joint), vascular dementia, and major depressive disorder.
A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated June 28, 2024, revealed Resident #27 had a Brief Interview for Mental Status score of 3/15, which indicated severe cognitive impairment.
Section GG revealed that Resident #27 had impairment on side to both the lower and upper extremity.
On 08/13/2024 at 02:20 PM, the surveyor conducted an interview with the facility administration which included the Director of Nursing DON), the Licensed Nursing Home Administrator (LNHA), and the [NAME] President of Clinical Services.
When asked how to properly transport a non-ambulatory resident, the DON told the surveyors, The resident should be transported from behind so that the staff and resident are moving forward in the same direction to see where you are going and for dignity issues.
NJAC 4.1(a)(12)
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River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
The surveyor observed what appeared to be tan/brown tube feed formula to be spilled on the floor and on the base of the IV pole.
On 08/07/2024 at 08:26 AM Resident #101 was observed lying in bed with the head of the bed (HOB) slightly elevated. TF is not hung or infusing on this observation.
The IV pole base remains covered with an unidentified tan colored substance on the base of the IV pole.
On 08/08/2024 at 08:24 AM Resident #101was observed lying in bed with HOB elevated.
Enteral pump is turned off and no tube feed is present.
Base of IV pole and floor are stained/covered with an unidentified tan/brown substance that resembles an enteral feed, as seen on previous observations.
On 08/12/2024 at 11:10 AM Resident #101was observed lying in bed and receiving intravenous fluids.
No TF was hung at this time. IV pole base is covered with an unidentified tan/brown substance that is dried onto the base.
Appears to be dried tube feed formula that spilled.
On 08/13/2024 at 08:35 AM Resident #101 was observed lying in bed with HOB elevated.
Tube feeding of Jevity 1.5 (an enteral formula to provide nutrition to residents that are unable to eat by mouth). IV pole base is covered with what appears to be dried enteral feeding.
The surveyor conducted an interview with the Housekeeping Assistant assigned to Resident #101's room.
When asked who was responsible for cleaning of IV poles the house keeping assistant (HKA #2) stated that housekeeping staff were responsible for the maintenance/cleaning of IV poles in the facility. HKA #2 agreed that the IV pole needed cleaning and agreed that enteral formula had been spilled on the IV pole base.
On 08/13/2024 at 09:45 AM the surveyors conducted an interview with the facility Director of Environmental Services and Laundry (DEVS).
When asked who was responsible for the cleaning of IV poles the DEVS responded, We are responsible to clean the IV poles.
They are scheduled once a week to be cleaned but they can be cleaned daily if need be.
On 08/13/2024 at 02:26 PM during an interview with facility administration the DON and LNHA confirmed housekeeping/environmental services was responsible for cleaning IV poles as well as the person making the spill.
NJAC 8:39-31.4(a)
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River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
During an interview with the surveyor on 08/07/2024 at 09:10 AM, Registered Nurse/Unit Manager (RN/UM #1), stated that there was no care plan for the respiratory care for Resident #372. RN/UM #1 added that it was ultimately her responsibility to assure that a care plan was in place. 8:39-11.2 (e)
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River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
During an interview with the surveyor on 08/14/2024 at 09:10 AM, the Director Of Nursing (DON) said there was no order to transfer Resident #126 to the hospital.
The surveyor asked should there have been an order and she replied, Yes.
- On 8/13/24 at 8:47 AM, the surveyor reviewed the medical record for Resident #137, a hospitalized
resident.
A review of the admission Record reflected the resident was admitted to the facility with diagnoses which included injury of the cervical (neck) spinal cord, muscle weakness and difficulty walking.
A review of the Progress Notes (PN), Health Status Note, dated 8/3/24 at 8:14 PM, the resident was observed with SOB (shortness of breath) and skin pale in color.
The NP (Nurse Practitioner) was contacted and ordered resident to be sent out [to the hospital] via 911.
A review of the Medication Review Report for August 2024 did not reveal a physician's order for the resident to be sent to the hospital on 8/3/24.
On 8/14/24 at 8:42 AM, the surveyor interviewed the DON who stated there should be a physician's order for a resident to be transferred to the hospital.
The DON acknowledged there was no order for Resident #137 to be transferred to the hospital in the resident's medical record.
NJAC 8:39-11.2(b); 27.1(a)
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(gastrointestinal) system.
When asked where this would be documented, the DON replied, It should be
On 08/12/2024 at 11:09 AM, the surveyor reviewed the evidence with the DON who confirmed it (the
NJAC 8:39-27.1(a)
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River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
The surveyor asked RN/UM #1 to look at the resident's orders. RN/UM #1 then told the
with the RN/UM #1 that the nurses are documenting pulse ox's on oxygen. RN/UM #1 looked at the
During an interview with the surveyor on 08/13/2024 02:40 PM, the facility Director of Nursing (DON) was asked what the facility policy was regarding oxygen use.
The DON said they have to have an order from MD (physician) with amount of oxygen needed, whether prn (as needed) or continuous, how given either nasal cannula or via mask, and a care plan.
NJAC 8:39-27.1(a)
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River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
The surveyor reviewed the medical record for Resident #94 on 08/06/2024 at 11:43 AM.
A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included chronic kidney disease; dependence on renal dialysis; and type II diabetes mellitus.
A review of the Order Summary Report included a physician's order (PO) dated 5/13/24, for hemodialysis every Tuesday, Thursday, and Saturday; 10:45 AM- 2:30 PM return time, wheelchair transport.
A review of the most recent comprehensive Minimum Data Set (MDS) dated [DATE], reflected the resident had a brief interview for mental status score of 15 out of 15, which indicated a fully intact cognition. A further review of the MDS indicated the resident had received dialysis treatments while in the facility.
On 8/12/2024 at 11:07 AM, the surveyor interviewed the residents Licensed Practical Nurse (LPN #1) who stated Resident #94 received dialysis on Tuesday, Thursday, and Saturday, and that the facility communicated with the dialysis center using a communication book the resident would transport with them. LPN #1 further explained the facility nurse would fill out the top portion with the resident's vital signs and the dialysis center fills out the bottom portion.
A review of Resident # 94's dialysis communication book which included forms dated 8/1/24, 8/3/24, 8/6/24, 8/8/24, and 8/10/24 and observed the following: On 8/1/24 the dialysis center did not complete their portion of the Nurse Communication Record.
On 8/3/24 the facility did not complete their portion of the Nurse Communication Record.
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F 0698 ,
communication book from dialysis, so a new communication book/binder was created beginning
communication book and she confirmed two of the five forms provided were not completed in their entirety. RN/UM #1 stated the sending nurse was responsible to complete the top portion of the form and the dialysis nurse would complete the bottom portion of the form. RN/UM #1 further stated the nurse who received the resident after dialysis was responsible for reviewing the form and should call the dialysis center if the form was not completed.
On 8/13/2024 at 2:22 PM, the survey team met with the facility administration.
The Director of Nursing (DON) stated the nurses were responsible to ensure the dialysis communication form was completed in its entirety and sent with the resident to dialysis.
Then upon the return to the facility from dialysis the nurse should review the form for any treatments provided or recommendations. If the form was not completed from the dialysis center, then the nurse should have reached out to the dialysis center to have the form completed.
NJAC 8:39-27.1(a)
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River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
During an interview with the Director of Nursing (DON) on 08/13/2024 at 02:44 PM, the surveyor reviewed the Facility Assessment and asked the DON what was the facility's staffing pattern for nurses? The DON explained the following: PAV (Pavilion) 1 DAY 2 nurses EVE 2 nurses NIGHT 2 nurse PAV 2 DAY 2 nurses EVE 2 nurse NIGHT 1 nurse PAV 3 DAY 2 nurses EVE 2 nurses NIGHT 1 nurse.
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River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
counts.
The CP stated that the potency of the Fentanyl patches would have been affected if it were
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River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
Review of the Consultant Pharmacist's Medication Regimen Review for recommendations created between 6/23/2024 and 6/24/2024 revealed the following recommendation for Resident #89: Resident has been on Lasix for edema since 10/5/2023.
Please re-evaluate continuous need and consider discontinuing.
Has the edema resolved? Under the Follow-Through heading the following documentation was observed: Note written to physician.
A review of the Note To Attending Physician/Prescriber MRR Date: 6/24/2024 revealed the following: Resident has been on Lasix for edema since 10/5/2023.
Please re-evaluate continuous need and consider discontinuing.
Has the edema resolved? The following was documented under Physician/Prescriber Response: Agree signed and dated 7/2/24.
A review of Resident #89's progress notes dated 7/2/2024 and 7/3/2024 did not reveal any documentation concerning the discontinuation of the Lasix medication.
On 08/13/2024 at 08:53 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM #1) who was assigned to the unit that Resident #55 and #89 resided.
The surveyor asked LPN/UM #1 to describe the facility process for responding to the CP MRR. LPN/UM #1 told the surveyor The physician recommendations are given to the doctors in a folder monthly.
They respond to them and sign them and then they are given back to me. I (UM/LPN #1) take care of the monthly nursing recommendations. It is up to the physicians to handle and agree or disagree with the CP monthly medication regimen reviews.
During a follow-up interview with LPN/UM #1 on 08/14/2024 at 09:02 AM, the surveyor asked LPN/UM #1 if she had ever been responsible for discontinuing physician orders recommended by the CP. LPN/UM #1 replied, I've never had to discontinue an order from the physician side. I/we (nursing) are only responsible for nursing recommendations.
The physician is responsible for carrying out their own recommendations concerning consultant pharmacy recommendations.
On 08/14/2024 at 09:52 AM, the surveyor conducted an interview with the facility Director of Nursing (DON).
The surveyor asked the DON what the facility process was concerning the CP MRR.
The DON told the surveyor, The physician will discontinue the order, or they will provide nursing with a verbal order to discontinue a CP recommendation if they agree with the recommendation.
That applies to physicians and nurse practitioners.
For Resident #89 the Lasix order should have been discontinued on 7/2 or 7/3/2024.
Concerning Resident #55 Yes, the Dicyclomine should have been discontinued according to the physician checking Agree and signing and dating. I agree that there is a breakdown in the MRR process, and I take that seriously.
NJAC 8:39-29.3(a)(1)
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River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
Observation of the freezer revealed no internal thermometer was present to monitor the freezer temperature. On interview LPN/UM #1 stated, I was not aware that we had to do the freezer as well as the refrigerator. It makes perfect sense. I will get a thermometer.
NJAC 18:39-17.2(g)
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River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
will be ongoing.
Labeling is still a concern with compliance at 77% which is up from March Also in the
in the facility QAPI binder associated with the data collection for the expired medication QAPI plan for
Nursing Home Administrator copies of data collection for the QAPI plan for expired medication cart medications that was revealed via consultant pharmacist reports.
On 08/13/2024 at 01:09 PM, during an interview with the facility DON and ADON, the DON told the surveyors that they do not have any data collected for the expired medication QAPI plan for February or April of 2024 and that they cannot provide the surveyor with any data from the 2/2024 QAPI Action Plan related to pharmacy reports that have expired meds as a major concern.
The DON further told the surveyor that the reason they did not have any audits is because the QAPI plan did not work, and they are coming up with a new one. On 08/13/2024 at 02:32 PM, the facility told the surveyor when asked where the facility obtained a rate of 77% compliance on the April 2024 QAPI plan the DON told the surveyor that It's possible that the data reported came from the monthly CP visit.
NJAC 8:39-33.1(c) 33.2(a)(b)(d)
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River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
The surveyor asked the laundry staff if she was wearing a cover and she responded, No, I wasn't wearing the cover when the surveyor came in.
The surveyor questioned the laundry staff member as to what the purpose of wearing the cover was and the laundry staff replied, Not messing with your clothes.
The laundry staff then put the apron on in the presence of the surveyor.
The surveyor then asked about the dryer.
The staff removed the cover/apron and draped it over the dirty laundry bin, removed her gloves and proceeded to open the dryer lint door.
The staff did not perform hand hygiene after removing her gloves.
During an interview with the Infection Preventionist (IP) on 08/08/2024 at 10:19 AM, the surveyor questioned what surveillance you perform in the laundry department.
The IP replied, I am here at 5am daily. I go through the laundry and make sure we have enough linen. I look to make sure everything is ok.
When asked what facility policy was regarding handling of soiled linen, the IP said, I am not familiar with the laundry policy regarding soiled linens.
During an interview with the surveyor on 08/13/2024 at 09:44 AM, the Director of Environmental Services and Laundry (DEVS) was questioned as to what the laundry staff are to wear while sorting soiled linens.
The DEVS replied, They are supposed to be covered up with gown, gloves, and mask.
The surveyor asked what gown he meant.
The DEVS said, They normally wear yellow gowns. I have never seen anybody wear the apron.
Gowns are back there and provided for them.
NJAC 8:39-19.4 NJAC 8:39-19.4 (a)(1)
The surveyors did not observe any data collection forms in the facility QAPI binder associated with the data collection for the expired medication QAPI plan for February or April of 2024. At this point the surveyors requested from the facility DON and/or Licensed Nursing Home Administrator copies of data collection for the QAPI plan for expired medication cart medications that was revealed via consultant pharmacist reports.
On 08/13/2024 at 01:09 PM, during an interview with the facility DON and ADON, the DON told the surveyors that they do not have any data collected for the expired medication QAPI plan for February or April of 2024 and that they cannot provide the surveyor with any data from the 2/2024 QAPI Action Plan related to pharmacy reports that have expired meds as a major concern.
The DON further told the surveyor that the reason they did not have any audits is because the QAPI plan did not work, and they are coming up with a new one. On 08/13/2024 at 02:32 PM, the facility told the surveyor when asked where the facility obtained a rate of 77% compliance on the April 2024 QAPI plan the DON told the surveyor that It's possible that the data reported came from the monthly CP visit.
NJAC 8:39-33.1(c) 33.2(a)(b)(d)
315225
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 315225 B.
Wing 08/14/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
The surveyor reviewed the unsampled resident's electronic health record and noted an order for pantoprazole 40 mg give 1 (one) tablet orally one time a day for GERD was ordered on 05/24/22 and was discontinued on 03/03/24.
The discontinued medication remained within the resident's active inventory of medications through 08/07/24, until surveyor inquiry.
2. On 08/07/2024 at 11:34 AM, the surveyor reviewed the Narcotic (a controlled substance used to dull the senses and relieve pain) Book in the presence of LPN #1 for the Pavilion Two Unit Short Hall Medication Cart.
The surveyor reviewed the Narcotic Count Record for August 2024 and noted that LPN #1, who was scheduled to work the 7 AM to 3 PM shift, had already signed his name in the space provided for the Offgoing Nurse Signature for the 3 PM to 11 PM shift.
When the surveyor asked why he signed the Narcotic Count Record prior to performing a narcotic count of all controlled medications within the medication cart with the Oncoming Nurse he stated, So I do not forget.
On 08/07/2024 at 11:56 AM, the surveyor interviewed RN/UM #1 of Pavilion Two who stated that the purpose of the narcotic count was for the incoming and outgoing nurses to document that they were in agreement that the count was correct.
The RN/UM #1 stated that it was not acceptable to sign out for the outgoing shift before the count was completed. LPN #1 was present at that time, and stated that he was mistaken.
On 08/08/2024 at 12:48 PM, the surveyor conducted a telephone interview with the Consultant Pharmacist (CP) who stated that the 7 AM to 3 PM nurse absolutely should not have signed out as the outgoing nurse on the 3 PM to 11 PM shift because they did not count with the incoming nurse.
The CP stated that the whole idea was to make sure that the narcotic count was okay.
The CP stated, It is not okay to pre-sign.
On 08/08/2024 at 1:33 PM, the surveyor interviewed the DON who stated that the process for the narcotic count was to sign to verify what you see at that point, because things change.
The DON stated that both the incoming and outgoing nurses should count what they have in the medication cart together and then sign afterward.
The DON further stated, We should never pre-sign for anything.
3. On 08/07/2024 at 12:13 PM, the surveyor observed the DON and RN/UM #1 as they performed a cycle count of back up controlled medications stored within the automated medication dispensing system.
The DON stated that the Registered Nurse Supervisor and the Infection Preventionist (IP) performed a cycle count daily.
315225
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 315225 B.
Wing 08/14/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.