Riverfront Rehabilitation And Healthcare Center

F-F755

Based on observation, interview, and review of pertinent facility records, it was determined that the facility Quality Assessment and Performance Improvement (QAPI) committee failed to utilize the Facility Performance Improvement Plan (PIP) to follow the facility process to measure and utilize data for checking medication carts three times weekly for expired medications. This deficient practice was evidenced by the following:

On 08/13/2024 at 09:51 AM, the surveyor reviewed the facility policy titled Quality Assurance Performance Improvement, Date Reviewed/Revised: 9/14/23. The following was revealed under Purpose: Our Quality Assurance and Performance Improvement Program (QAPI) represent our facility's commitment to continuous quality improvement. The program ensures a systematic performance evaluation, problem analysis, and implementation of improvement strategies to achieve our performance goals. The following was revealed at II. Guidelines for Governance and Leadership:

a. Nursing and Facility Administration are responsible and accountable for developing, leading, and closely monitoring a QAPI program.

Under an additional Policy heading on page 3 of 7 of the QAPI policy the following was revealed:

5. The QAPI Team oversight responsibilities shall include, but are not limited to the following:

Utilize facility data to identify opportunities to improve systems and care. Data may include, but is not limited to; grievance logs, medical record review, skilled care claims, fall log, pressure ulcer log, treatment logs, staffing trends, incident and accident reports, quality measures, survey outcomes, etc.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 315225 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 1. On 08/13/2024 at 10:50 AM, the surveyors, while reviewing the facilities QAPI policy and procedure and QAPI plan asked the facility administration to provide the surveyors with 3 current QAPI's that the facility was Level of Harm - Minimal harm or addressing. After receiving the binder, the surveyors observed that in February of 2024 the facility identified potential for actual harm via pharmacy reports that expired medications were a major concern. Root cause analysis identified 1.) expired medications on carts and medication rooms were found during inspection by the consultant Residents Affected - Few pharmacist (CP). 2. Nurses were not checking medication carts for expired medications. Goals & Objectives were defined as: 1.) To have all expired meds out of medication carts and stock rooms. 2. Educate all Licensed Practical Nurses about checking carts for expired medications. Responsible team members were identified as DON (Director of Nursing), ADON (Assistant Director of Nursing), and LPN (Licensed Practical Nurse). Estimated and Completion date were ongoing. Education was identified as being on going. The Comments section of the February 2024 QAPI Action Plan noted that Education will be ongoing and that medication carts will be checked periodically for expired medications three (3) times per week. A copy of the April 2024 QAPI plan revealed that Pharmacy reports have expired medications as a major concern. Root Cause Analysis revealed the following: 1.) Expired medications on carts, medication rooms were found

during inspection. and 2.) Charge nurses are not checking carts for expired medications. In the Action Items section, the QAPI plan revealed 1. LPN staff will be educated on dating and disposing of medications. and 2. All carts will be checked periodically for expired medications. Start date was listed as 2/2024 and responsible team members were DON, ADON, LPN. Estimated and Actual Completion Date were identified as ongoing.

The following was documented in the Comments section of the plan: Education will be ongoing. Labeling is still a concern with compliance at 77% which is up from March Also in the Comments section, it was stated that Checks will be done regularly. 4/24 - Currently all expired medications are out of med rooms and carts.

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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 315225 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 37547 potential for actual harm Based on observation, interviews, and review of pertinent facility documentation, it was determined that the Residents Affected - Few facility failed to a.)properly store and maintain both sterile and non-sterile medical supplies in a safe and sanitary manner and b.) ensure that laundry staff used the appropriate personal protective equipment while handling items that were likely contaminated with infectious bodily fluids. This deficient practice was identified for 2 of 2 medication storage rooms reviewed for the medication storage task and 1 of 1 laundry staff and was evidenced by the following:

On 08/07/2024 at 9:41 AM, during the inspection of the Pavilion Three Medication Storage Room, in the presence of Licensed Practical Nurse Unit Manager (LPN/UM #1) the surveyor observed: three enema kits, two packages of heel booties, and a box of wound treatment supplies which included: a half filled box of fifty count 4 x 4 gauze pads, a fifteen count box of border gauze dressings, two rolls of gauze, and a roll of paper tape that were stored beneath the handwashing sink. LPN/UM #1 stated that Central Supply stocked the supply room and placed the items under the sink. LPN/UM #1 stated that she never checked under the sink and did not know that the supplies were there. LPN/UM #1 further stated that the issue with the items being stored under the sink was contamination.

On 08/07/2024 at 12:45 PM, during the inspection of the Pavilion Two Medication Room in the presence of

the Registered Nurse/Unit Manager (RN/UM #1), the surveyor observed a one liter bag of 0.45% sodium chloride injection (Intravenous fluid solution) and noted that the outer plastic packaging was previously opened and remained in storage. The RN/UM #1 stated that the effectiveness of the medication could be compromised.

On 08/08/2024 at 10:15 AM, the surveyor interviewed the Infection Preventionist (IP) in the presence of the survey team. The IP stated that he did not know the facility policy for storing items beneath the handwashing sink. The IP stated that the wound treatment supplies would no longer be sterile or usable if it were to become wet beneath the sink. The IP stated that if either the enema kits or heel booties got wet they would become contaminated and could not be used. The IP stated that the facility did not have a policy that pertained to the prohibited storage of medical supplies beneath the sink.

On 08/08/2024 at 12:36 PM, the surveyor interviewed the Central Supply Director (CSD), who stated that

she placed items from central supply in the medication storage rooms in the cabinets and storage bins. The CSD stated she would never store anything under the sink because if it happened to leak, she did not want

the leakage to reach the stock. The CSD stated, We are not allowed to place anything under the sink because it was a rule put into place by both the former and current administrators, and was an infection control issue. The CSD stated that the nurses have access to the area and put things away. The CSD further stated that the cabinets beneath the sinks should be fixed, and not opened.

On 08/08/2024 at 1:33 PM, the surveyor interviewed the Director of Nursing (DON) who stated that it was unsanitary and we risked our dressings no longer being sterile if fluids were on on the wound treatment supplies and they went into someone's wound. The DON stated that nothing should be stored under the handwashing sink.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 315225 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 At that time, the DON further stated that a liter of IV fluids should not have been placed back into storage

after it was opened, as the package should have remained sterile and not opened until ready for usage. Level of Harm - Minimal harm or potential for actual harm 34423

Residents Affected - Few On 08/12/2024 at 01:12 PM, a review of a facility policy titled Linen Handling Policy with a reviewed date of 6/3/2024 revealed under 3: Personal Protective Equipment (PPE) for laundry Staff

Practice hand hygiene before and after removing PPE.

Wear tear resistant gloves when handling and laundering soiled linens.

If there is a risk of splashing (e.g. hand-washing laundry) Laundry staff should also wear gowns or aprons and face protection .

On 08/12/2024 at 09:37 AM, the surveyor observed the following in the facility laundry area:

Observed a laundry staff wearing a surgical mask under her nose and gloves while emptying soiled laundry from plastic bags into soiled laundry bins.

When the surveyor asked what she was required to wear when sorting soiled laundry, she replied, I have to wear gloves, mask, and cover (apron) to keep clothes clean. 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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 315225

F-F867

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to ensure: a) a discontinued and expired medication (pantoprazole, used to treat gastroesophogeal reflux disease /GERD, a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach) was removed from active inventory b) maintain an accurate accountability for controlled substances within the medication administration cart c) a controlled medication that was expired was removed from an automated medication dispensing system. This deficient practice was identified for 1 of 3 medication carts, and 1 of 1 automated medication dispensing system reviewed during

the medication storage task.

A review of the facility policy, Medication Administration (Reviewed 06/24) revealed the following: .Check the expiration date on medication label.

A review of an undated facility policy, 6.0 Inventory Control of Drugs revealed the following: Controlled drugs are inventoried and documented under proper conditions with regard to security and state/federal regulations.

.Schedule II medications are counted by the oncoming nurse and the outgoing nurse at least once (1) a day or at the change of each shift and documented on a Controlled Drug Count Verification (Shift Count Sheet for Narcotics).

A review of the facility policy, 4.0 Schedule II Controlled Substance Medication (Revised 10/01/18) revealed

the following: .An inventory count of all CDS (controlled dangerous substances) medications stored on each nursing unit shall be performed at each change of shift by both the incoming and outgoing nurse. Both nurses are responsible for the count and must sign the inventory count form.

This deficient practice was evidenced by the following:

1. On 08/07/2024 at 11:23 AM, during a medication cart inspection of the Short Hall Medication Cart on the Pavilion Two Unit in the presence of Licensed Practical Nurse (LPN #1), the surveyor noted a bingo card (unit dose medication blister packaged onto a multiple-dose card) that contained pantoprazole 40 milligrams (mg) that was ordered for Resident #8 had expired on 08/01/24. When interviewed at that time, LPN #1 stated that the resident received the medication this morning. LPN #1 further stated that he had not seen the expiration date.

On 08/07/2024 at 11:56 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM #1) who stated that staff should check medications before the medication pass to make sure that they were not expired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 31 315225 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 On 08/08/2024 at 12:48 PM, the surveyor conducted a telephone interview with the Consultant Pharmacist (CP) who stated that nursing should look at the expiration date on the medication prior to administration. The Level of Harm - Minimal harm or CP stated that she expected nursing to look through their carts each time that they handled medications. The potential for actual harm CP stated that as a CP, part of her role was to check the bingo cards during cart inspection.

Residents Affected - Few On 08/08/2024 at 1:33 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the expiration date should have been on the back of the blister pack and the nurse should have looked at the expiration date prior to administration.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 31 315225 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During the inventory count, the DON stated that eight of eight Fentanyl (an opioid pain reliever) 50 microgram/hour (mcg/hr) patches, expired on 07/20/24. The DON stated that the expired medication should Level of Harm - Minimal harm or have been identified during the daily cycle count. The DON stated the pharmacy also should have known the potential for actual harm medication was expired. The DON stated that the efficacy (ability to produce a desired or intended result) would be compromised if the medication were administered. The DON further stated that the expired Residents Affected - Few Fentanyl patches should have been removed from the automated dispensing system on 07/01/24, as the facility went by the first day of the month.

On 08/08/2024 at 12:48 PM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that there should not have been expired Fentanyl patches in the automated medications dispensing system. The CP stated that the staff should have checked the expiration dates when they did the counts. The CP stated that

the potency of the Fentanyl patches would have been affected if it were expired and the resident may have received less medication if the patch were administered. The CP stated, There is no excuse for expired medications, they should be checking those things.

NJAC 8:39-29.4(g); 29.7 (c); 29.1(e)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 31 315225 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40039

Residents Affected - Some Based on observation, interview, review of the medical record, and review of pertinent facility records it was determined that the facility failed to follow through on recommendations made by the consultant pharmacist (CP) during their monthly medication regimen review (MRR) in a consistent and timely manner. This deficient practice was identified for 2 of 5 residents reviewed for unnecessary medications, (Resident #55 and Resident #89) and was evidenced by the following:

The surveyor reviewed the facility policy on 08/13/2024 at 10:45 AM, titled Medication Regimen Review Policy NO: ROP-32, Reviewed: 6/2/2024. The following was revealed under POLICY: It is the facilities policy to provide a Medication regimen review (MRR) for all residents admitted to the nursing facility. The following was revealed under Policy Explanation and Compliance Guidelines:

1. Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident with

the goal of promoting positive outcomes and minimizing adverse consequences associated with medication.

The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team.

4. The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and the reports must be acted upon.

c. The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

7. Upon completion of the MRR, the facility designee and/or physician, will respond to the recommendations

in a timely manner.

10. Each resident's drug regimen remains free of unnecessary drugs. An unnecessary drug is any drug when used:

a. In excessive doses, including duplicate therapy.

b. For excessive duration.

c. Without adequate monitoring.

d. Without adequate indications for its use.

e. In the presence of adverse consequences which indicate the dose should be reduced or discontinued.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 31 315225 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 1.On 08/06/2024 at 08:43 AM Resident #55 was observed lying in bed and asleep. Resident #55 did not respond to the surveyor voice. Level of Harm - Minimal harm or potential for actual harm A review of the Electronic Medical Record on 08/06/2024 at 12:01 PM revealed the following:

Residents Affected - Some According to the Admission Record Resident #55 had the following but not limited to diagnoses: Osteoarthritis of left knee, diabetes mellitus, encounter for attention to colostomy, and acquired absence of left toe.

A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated June 14, 2024, revealed that Resident #55 had a Brief Interview for Mental Status score of 15/15 indicating intact cognition. Section N of the MDS revealed Resident #55 received antidepressant, anticoagulant, opioid and hypoglycemic medications daily.

A review of the Order Summary Report revealed that Resident #55, as of 8/14/2024 had the following active order: Dicyclomine HCl (hydrochloric acid) Oral Tablet 20MG (milligram) (Dicyclomine HCl) Give 1 tablet by mouth every 12 hours as needed for Abdominal pain Order Status: Active Order Date: 01/19/2024.

A review of the July 2024 and August 2024 Medication Administration Record (MAR) revealed Resident #55 had not received Dicyclomine HCl oral tablet during the month of July or August 2024.

A review of the CP MRR Note To Attending Physician/Prescriber MRR Date: 6/24/2024 revealed the following CP recommendation: Recommend discontinuing PRN (as necessary) Dicyclomine. The resident has not used medication > (greater than) 60 days. A review of the Physician/Prescriber Response revealed that the physician/prescriber Agreed: and was signed and dated 7/2/24. A review of the Consultant Pharmacist's Medication Regimen Review document for recommendations created between 6/23/2024 and 6/24/2024 revealed the following recommendation: Recommend discontinuing PRN Dicyclomine. The resident has not used medication for > 60 days. Under the Follow-Through heading the following was documented: Note written to physician

2. On 08/06/2024 at 09:07 AM, Resident #89 was observed lying in bed with the head of the bed elevated. Resident #89 was asleep, and no maladaptive behaviors were exhibited on this observation.

A review of the Medical Record on 08/06/2024 at 10:37 AM revealed the following:

A review of the Admission Record revealed Resident #89 had the following but not limited to diagnoses: Chronic Obstructive Pulmonary Disease (a type of progressive lung disease), morbid obesity, hypertensive heart disease (high blood pressure), atherosclerotic heart disease, and paranoid schizophrenia.

A review of Resident #89's comprehensive MDS, dated [DATE REDACTED], revealed that Resident #89 had a Brief

Interview for Mental Status score of 15/15 indicating intact cognition. Section N of the MDS revealed that Resident #89 received a diuretic (promotes increased production of urine) daily.

A review of the Order Summary Report with Active Orders As Of: 08/14/2024, revealed Resident #89 had the following physician/practitioner order: Lasix Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time

a day for edema Order Status: Active Order Date: 10/04/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 31 315225 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 A review of Resident #89's comprehensive care plan revealed a care plan Focus: I am on diuretic therapy (Lasix) r/t (related to): HTN (hypertension) Created on: 05/24/2023. The following was revealed under Level of Harm - Minimal harm or Interventions: Ask physician to review medication for possible dose reduction every three months Created potential for actual harm on: 05/24/2023 and Administer medication as ordered and monitor for side effects. Report to MD as appropriate. Created on: 05/24/2023. Residents Affected - Some

A review of Resident #89's MAR for 7/1/2024 - 7/31/2024 revealed that Resident #89 received Lasix Oral Tablet 40 MG daily at 0800 (8:00 AM) for the dates of 7/1/2024 through 7/31/2024. A review of Resident #89's 8/1/2024 - 8/31/2024 MAR revealed that Resident #89 received Lasix Oral Tablet 40 MG daily from 8/1/2024 through 8/8/2024 (MAR was provided to surveyor on 8/8/2024).

On 08/08/2024 at 11:33 AM the surveyor conducted a review of the CP MRR for the past 6 month period.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 31 315225 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 NJAC 8:39-29.3(a)(1)

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 315225 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40039

Residents Affected - Some Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:

The surveyor reviewed a facility policy on 08/05/2024 at 12:02 PM, titled [company name] Dining Services Food Storage, undated. The following was revealed under Canned Fruits: Dented or bulging cans shall be placed on Damaged Goods Shelf and returned for credit. The following was revealed under Canned Vegetables: Dented or bulging cans shall be placed on Damaged Goods Shelf and returned for credit.

The surveyor reviewed a facility policy on 08/05/2024 at 12:02 PM, titled [facility name] Dining Services Pots and Pans - Sanitizing Solution, undated. The following was revealed under the heading SANITATION OF EQUIPMENT: NOTE: Allow all items to air dry. Towels shall never be used for drying. When items are dry, store in proper storage area.

On 08/11/2024 at 12:26 PM, the facility provided the surveyor with a copy of the facility policy for refrigerators in the pantries, Reviewed 2/2024. The policy revealed the following under the heading POLICY:

The facility recognizes the importance of ensuring that all foods are held at a safe temperature to ensure the safety of its residents. All refrigerators on the units will be monitored daily for correct temperatures. The policy did not address the monitoring of freezer temperatures.

On 8/5/2024 from 9:26 to 10:05 AM, the surveyors, accompanied by the facility Food Service Director (FSD), observed the following in the kitchen:

1. In the dry storage room a can of mushrooms on a multi-tiered rack had a significant dent on the seam. The FSD removed the can of mushrooms to the designated dented can area with the other dented cans that were removed for dents.

2. A stack of five (5) deep/full pans on a middle rack of the pot and pan storage rack were stored in the inverted position. The surveyor picked up the top pan with their hand and observed a clear, watery substance on the bottom surface of the pan beneath. Further observation revealed that the additional three (3) pans in the stack also were covered with a wet watery substance, a process known as wet nesting (occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow). The FSD removed the stack of five (5) pans from the pot/pan storage rack to be rewashed and sanitized.

On 08/08/2024 from 12:57 to 1:17 PM, the surveyors, accompanied by Unit Manager/Licensed Practical Nurse (UN/LPN #1) observed the following on the PAV1 (pavilion 1) pantry:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 315225 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 1. The surveyor reviewed the PAV1 Pantry Food Refrigerator Temperature Log, dated [DATE REDACTED]. The log revealed that the Refrigerator range for foods was 32-40 degrees Fahrenheit and Freezer: -10 to 0 F. Level of Harm - Minimal harm or Observation of the interior of the pantry freezer determined there was no internal thermometer in the freezer potential for actual harm and no temperatures were recorded for the [DATE REDACTED] PAV1 Pantry freezer on the temperature log only refrigerator temperatures. On interview the UM/LPN # stated that she was not aware that the freezer Residents Affected - Some required a thermometer and that the temperature needed to be monitored. UM/LPN # told the facility Infection Preventionist who was walking by that the unit needs a thermometer for the PAV 1 freezer in the presence of the surveyor.

On 08/08/2024 from 1:20 to 1:30 PM, the surveyor, accompanied by LPN/UM #1 observed the following in

the PAV3 (pavilion 3 pantry):

1. The temperature log, as described above for PAV1 had no freezer temperatures recorded for the dates 8/1 thru 8/8/2024. 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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 315225 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 40039

Residents Affected - Few Cross Reference