River Front Rehabilitation And Healthcare Center
RIVER FRONT REHABILITATION AND HEALTHCARE CENTER in PENNSAUKEN, NJ — inspection on November 21, 2025.
Found 7 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
Review of R29's admission Record, dated 09/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE].
The resident's diagnoses included osteoarthritis and chronic viral hepatitis.
Review of R29's quarterly MDS) assessment with an ARD of 08/08/25 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact.
Review of R29's Smoking/Nicotine Devices Assessment, dated 12/02/24 and found in the EMR under the Assessment Tab, revealed R29 was a smoker and revealed R28 preferred to smoke in the morning and the afternoon.
During an interview with R29 on 09/02/25 at 4:10 PM, R29 confirmed residents could smoke three times per day for 20 minutes each time and were allowed to have only two cigarettes at each smoke time. R29 stated she/he would like to smoke after dinner, but was not allowed to. R29 further stated she/he did not understand why residents were only allowed to have two of their cigarettes at each smoke break since the cigarettes were the property of each resident. NJAC 8:39-27.1 (a)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/21/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
River Front Rehabilitation and Healthcare Center
5101 North Park Drive Pennsauken, NJ 08109
SUMMARY STATEMENT OF DEFICIENCIES
Review of the undated Hallway Duty List, provided by the ED, noted areas to be cleaned as well as resident rooms, however no specifics were identified as to what that involved. An undated Curtain Wash Schedule was provided for resident rooms only. An undated Shower Room Cleaning form listed the following to be completed every two to five days: Clean shower bed, clean shower chair, wipe handrails, clean walls, wash shower curtains, check sharps box, pull trash, and scrub floors.
Review of the Wheelchair Cleaning Log from 01/25 - 08/25 noted wheelchairs were cleaned every three months.
Review of the Maintenance TELS log, provided by the MD, noted facility checks to be completed, none of which was listed above. 2.
During an initial tour conducted of the facility on 09/02/25 from 11:00 AM - 11:30 AM, the following concerns were noted related to the facility physical environment: Walls in common areas such as hallways and day areas and in resident rooms on all three floors/units in the facility were scuffed, dirty (with brown stains and light colored streaks).Floors in resident rooms and the common hallways on all three units were extremely sticky and the floors were grimy and dirty in corners and against baseboards throughout the units.Door frames at resident room and common room entries were dirty, stained and peeling on all three floors/units.Door numbers were partially or completely missing for many of the resident and common rooms throughout the facility.Trash a debris was observed on floors throughout all three floors/units, but particularly on the second and third floor units.The was a strong urine odor on the second and third floors/units at the lower number end of each hall.Heating/air conditioning registers in resident rooms and common areas on the second and third floor units were dirty and many were broken.
During a group interview with 11 residents, including the Resident Council President and Resident Council [NAME] Present, conducted on 09/02/25 at 1:00 PM, the group reported facility bathrooms (in resident rooms) were nasty (dirty), the facility walls were very dirty and needed to be cleaned, the toilet in the hallway bathroom on the second floor had been broken and unusable for four days, shower rooms throughout the facility were dirty, floors throughout the facility were always sticky, and window screens throughout the facility were broken.
During a tour conducted with the Maintenance Director, the Director of Housekeeping and Laundry, the [NAME] President of Environmental Services, and the Administrator on 09/05/25 from 10:30 AM - 11:20 AM, all four staff members confirmed the above documented environmental concerns. NJAC 8:39 -31.8(10)NJAC 8:39 -31.4(a)(f)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/21/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
River Front Rehabilitation and Healthcare Center
5101 North Park Drive Pennsauken, NJ 08109
SUMMARY STATEMENT OF DEFICIENCIES
During an interview with the Administrator 09/03/25, she confirmed the above stated injury of unknown origin was not reported to the SA until 07/01/25.
During an interview with the BOM, the [NAME] President of Clinical, the Regional Nurse Consultant, and the Administrator on 09/04/25 at 11:40 AM, the Clinical President of Clinical and the Regional Nurse Consultant confirmed R2's injury of unknown origin was expected to have been reported to the SA within two hours of identifying the injury and confirmed the report submitted to the SA by the facility on 07/01/25 was submitted late. 3.
Review of R15's admission Record, dated 09/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE].
The resident's diagnoses included schizoaffective disorder and chronic kidney disease.
Review of R15's admission MDS assessment with an ARD of 09/04/25 and found in the EMR under the MDS tab, indicated a BIMS score of three out of 15 which indicated the resident was severely cognitively impaired.
Review of R15's Progress Notes, dated 09/01/25 at 9:15 PM and found in the EMR under the Notes Tab, indicated This writer was made aware that two resident was arguing.
This writer went to investigate and notice (R16) and (R15) facing each other.
This writer immediately separated both resident (for) safety.
Resident was assessed and found to have no injuries (R15) was brought back to his room and place on 1:1[one to one monitoring].
The resident was also reminded of his room change from 130A to 324B.
Family, DON, and MD (Medical Doctor) made aware.
Review of R16's admission Record, dated 09/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE].
The resident's diagnoses included vascular dementia and anoxic brain damage.
Review of R16's quarterly MDS assessment with an ARD of 07/11/25 and found in the EMR under the MDS tab, indicated a BIMS score of five out of 15, which indicated the resident was severely cognitively impaired.
Review of R16's Progress Notes, dated 09/01/25 at 9:49 PM and found in the EMR under the Notes Tab, indicated DON made aware by supervisor that resident had a verbal altercation with another resident (R15).
Residents immediately separated and patient placed on a 1:1.
Review of the facility's investigation documentation related to the above allegation of potential resident to resident verbal abuse revealed the incident was reported to the SA on 09/02/25 at 9:30 AM (almost 12 hours after the incident occurred).
During an interview with the Administrator 09/03/25, she confirmed that the above stated resident to resident altercation was not reported to the SA until 09/02/25.
During an interview with the Business Office Manager (BOM), the [NAME] President of Clinical, the Regional Nurse Consultant, and the Administrator on 09/04/25 at 11:40 AM, the Clinical President of Clinical and the Regional Nurse Consultant confirmed R15 and R16's verbal altercations was expected to have been reported to the SA within two hours of observation of the incident and confirmed the report submitted to the SA by the facility on 09/02/25 was submitted late. NJAC 8:39-9.4(f)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/21/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
River Front Rehabilitation and Healthcare Center
5101 North Park Drive Pennsauken, NJ 08109
SUMMARY STATEMENT OF DEFICIENCIES
Review of R2's admission Record, dated 09/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE].
The resident's diagnoses included dementia, cerebral ischemia and Chronic Obstructive Pulmonary Disease.
Review of R2's quarterly MDS assessment with an ARD of 07/18/25 and found in the EMR under the MDS tab, indicated a BIMS score of zero out of 15 which indicated the resident was severely cognitively impaired.
Review of R2's Progress Notes, dated 06/29/25 10:00 AM, entered into the resident's record on 06/30/25 at 3:34 PM, and found in the EMR under the Notes Tab, indicated Aide (Certified Nursing Assistant (CNA6) stated that the resident refused care and out of nowhere the resident started swinging his backscratcher at her.
Writer went to resident's room to speak with resident, resident denied that he tried to hit Aide. PT (patient) teaching was giving for refusal of care.
Review of R2's Progress Notes, dated 06/30/25 11:47 AM and found in the EMR under the Notes Tab, indicated Resident noted with bruising and discoloration to right hand, area cleansed with soap and water and applied an ice pack to area.
Full ROM (Range of Motion) to both hands noted with no facial grimacing when touched or using affected hand .
Review of the facility's investigation documentation, dated 6/29/25, related to R2's bruise of unknown origin revealed the incident was not fully investigated per the facility's abuse policy/requirements.
The investigation did not include interviews with staff members present on the day of the event, during which it was reported R2 attempted to strike CNA6 with his/her reacher and CNA6 pulled the reacher from his/her hand to ensure abuse of R1 by CNA6 did not occur during that incident, resulting in the bruising to R1's hand.
During an interview with the Administrator 09/03/25, she confirmed interviews had not been conducted with staff present on the day of the event that occurred between CNA6 and R1 to ensure no abuse of R2 by CNA6 had been perpetrated.
The Administrator stated that the CNA was suspended.
During an interview with the Business Office Manager (BOM), the [NAME] President of Clinical, the Regional Nurse Consultant, and the Administrator on 09/04/25 at 11:40 AM, the Clinical President of Clinical and the Regional Nurse Consultant confirmed R2's injury of unknown origin was expected to have been thoroughly investigated, including interviews with any staff who was present at the time of/may have had direct knowledge about the events which might have caused the injury to R2. NJAC 8:39-27.1(a)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/21/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
River Front Rehabilitation and Healthcare Center
5101 North Park Drive Pennsauken, NJ 08109
SUMMARY STATEMENT OF DEFICIENCIES
Review of the Physician Orders located under the Orders tab in the EMR revealed R8 received an order for a Life Vest on 09/19/24.
The order noted Change life vest battery every day shift.
Life vest manufacturer [NAME] 1-8005433267serial # 58020305.
Check [NAME] monitor for function and placement.
Review of the 09/19/24 Comprehensive Care Plan located under the Care Plan tab in the EMR revealed The resident has altered cardiovascular status r/t (related to) CHF (congestive heart failure), afib (atrial fibrillation) use of life vest.
The goal was identified as The resident will be free from complications of cardiac problems through the review date.
The interventions listed Assess for shortness of breath and cyanosis every (specify).
Encourage low fat, low salt intake.
The care plan failed to address the cleanliness of the Life Vest, personal hygiene when utilizing a Life Vest, responding to alarms, and when to notify the resident's physician in the comprehensive care plan for R8 who utilized a Life Vest, a wearable defibrillator.
Review of the Treatment Administration Records (TAR) for the months of 09/24, 10/24, 11/24, and 12/24, located under the Orders tab in the EMR, revealed the nursing staff were changing the battery every day and monitoring the [NAME] for function and placement every shift.
During an interview with the Minimum Data Set Coordinator (MDSC) on 09/05/25 at 2:16 PM, the MDSC stated, We all work on the care plans, but I did not complete (R8's).
During an interview with the Director of Nurses (DON) on 09/05/25 at 2:16 PM, the DON stated, I was not employed at that time, I cannot answer.
During an interview on 09/05/25 at 2:30 PM, the Pavilion I Unit Manager (PAV1UM) stated, I do the care plans. I remember (R8). I don't know why (R8's) care plan did not address the specifics of the Life Vest. We changed the battery every day.
Review of the Life Vest Policy and Procedure, dated 11/2024, provided by the Regional Nurse Consultant revealed Nursing home staff must provide safe and competent care for residents utilizing the LifeVest wearable defibrillator.
This includes ensuring proper use, monitoring, and maintenance of the device, as well as providing education to staff and residents to prevent complications and ensure effective operation.Daily Care/Device Inspection identified Check the LifeVest daily for proper positioning, cleanliness, and secure fit.
Inspect electrode pads and battery connections to ensure the device is functioning.
Assist residents in maintaining hygiene without compromising the LifeVest's functionality.
When removed for bathing, ensure the device is promptly re-worn as instructed by the manufacturer.Ensure spare, fully charged batteries are available.
Replace the battery per the manufacturer's instructions to avoid interruptions in monitoring.
Responding to Alarms/Non-Emergency Alarms: If the LifeVest issues a non-emergency alert (e.g., low battery, poor connection), address the issue following the manufacturer's troubleshooting steps.
Document any actions taken and notify, the resident's physician if necessary.
Emergency Alarms (Shock Delivery): If the LifeVest delivers a shock:l.
Monitor the resident's condition immediately. 2.
Call 9l1 and notify the physician for further assessment. 3.
Record the event in the residents' medical chart, including the time, observed symptoms, and response to the shock.
NJAC 8:39-27.1(a)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/21/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
River Front Rehabilitation and Healthcare Center
5101 North Park Drive Pennsauken, NJ 08109
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 09/04/25 at 8:58 AM, the DD stated, That's a good question, when asked whose responsibility it was to clean the vents.
During a tray line observation on 09/04/25 at 12:00 PM, the above conditions were identified to the Regional Food Service Director (RFSD).
The RFSD was unable to clarify who was responsible for cleaning the vents, fixing the rollers on the tray table, removing the rust from the prep tables, cleaning the fan and putting a front on the fan to cover the blades.
Review of a cleaning schedule, dated Week of 8/25-8/30, provided by the RFSD and the DD on 09/05/25 at 12:02 PM, revealed there were no cleaning job for the vents, ice machine, or the floor fan.
The RFSD said they were going to have the Maintenance Director (MD) fix the latches on the insulated food carts.
There was no evidence that the insulated food carts had been identified to require repairs prior to 09/05/25. A Policy and Procedure for kitchen cleaning was not provided prior to the exit on 09/05/25 at 3:30 PM. NJAC 8:39-17.2(g)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/21/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
River Front Rehabilitation and Healthcare Center
5101 North Park Drive Pennsauken, NJ 08109
SUMMARY STATEMENT OF DEFICIENCIES
Review of the facility's pest control logs, dated 06/01/25 through 09/05/25, revealed multiple entries indicating flies and/or cockroaches/water bugs had been reported on all three of the facility units during that time period.
During the initial tour of the facility on 09/02/25 from 11:00 AM - 11:30 AM, at least 15 flies were observed flying about on the third floor unit, a very large dead roach was observed laying upside down in the entry to room [ROOM NUMBER] on the second floor unit, at least 10 flies were observed flying about on the second floor unit, and four flies were observed flying about on the first floor unit.During a tour of the facility on 09/03/25 from 10:10 AM - 10:45 AM, two flies were observed flying about and around the non-interviewable resident in room [ROOM NUMBER]-B.During a tour of the facility with the Maintenance Director (MD), the Director of Housekeeping and Laundry, the [NAME] President of Environmental Services and the Administrator on 09/05/25 from 10:30 AM - 11:20 AM, multiple flies were observed flying about on all three floors of the facility.During the group interview conducted with 11 residents, including the Resident Council President and Resident Council [NAME] President, on 09/03/25 at 1:00 PM, the group unanimously indicated flies were an ongoing problem in the building and the residents stated they also frequently saw large black water bugs in the facility in common areas as well as their individual rooms.
One resident stated she/he had just seen a large black water bug in his room the previous night.
Three residents confirmed they had seen flies in the building on the day of the interview.
The residents further indicated ants were sometimes a problem on the second floor unit around the nurse's desk.
All of the residents confirmed the pests were bothersome to them.
During an interview with Certified Nursing Assistants (CNA)3 and CNA4 on 09/03/25 at 4:45 PM, both confirmed they had recently seen ants around the second floor nurse's desk.
During an interview with the Director of Housekeeping and Laundry and the [NAME] President of Environmental Services on 09/05/25 at 1:33 PM, both confirmed the observation of multiple flies on all three units of the facility during the tour conducted on 09/05/25.
The Director of Housekeeping and Laundry confirmed he had received recent reports of flies in the facility and stated he was aware of sightings of water bugs in the facility. He stated all facility staff was expected to document sightings of pests in the pest control books kept on each unit and he stated the pest control company was in the facility every Friday. He stated the pest control company provided pest control based on reports of pests received during the week prior to each visit.
During an interview with the Administrator on 09/05/05 at 2:00 PM, she stated her expectation was the facility should be free of pests.
N.J.A.C. S 8:39-31.5
Facility ID: