Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Front Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to Offer Recommended Pneumococcal Vaccines: The facility did not document offering PCV20 or PCV21 to three residents who had received PPSV23, and the records showed no evidence that the residents or their representatives were given the opportunity to receive the recommended pneumococcal conjugate vaccine. The Regional Nurse Consultant and IP reviewed the EMRs and confirmed the residents had only received Pneumovax 23, while the facility policy did not match current CDC guidance.
Resident Not Included in Care Planning Process: A cognitively intact resident was not shown to have been invited to subsequent care conferences or to have participated in the care planning process. The EMR and IDT meeting documents lacked evidence of invitations, and the SSD confirmed there was no documentation that the resident was invited or participated in the care conference.
Failure to protect a resident from resident-to-resident abuse occurred when one cognitively impaired resident struck another resident after a brief interaction at the nurses’ station. The assaulted resident sustained a swollen lip and lost two front teeth, while staff interviews and the incident investigation noted neither resident had prior behavior concerns before the event.
Failure to arrange a cataract surgery appointment for a resident with impaired vision. An optometrist ordered outside cataract surgery, but after one facility denied the appointment due to the resident’s weight, there was no evidence of further attempts to locate another facility. The resident reported not being able to see, while the LPN said the Unit Secretary handled the calls and the DON was unaware an appointment was needed.
Facility staff restricted cognitively intact residents' access to outdoor areas and limited smoking opportunities, allowing only three supervised smoke breaks per day with a maximum of two cigarettes per session. Both smokers and non-smokers were unable to access the patio at their leisure, and staff cited safety concerns as the reason for these restrictions. Residents expressed dissatisfaction with the lack of individualized consideration for their preferences and the inability to go outside or smoke according to their own routines.
Surveyors found that the facility failed to maintain a clean, safe, and homelike environment, with observations of dirty and damaged equipment, unclean and sticky floors, broken furniture, missing or damaged window screens, and inadequate cleaning of shower rooms and vents. Residents and staff confirmed these issues, and review of facility policies and logs showed a lack of effective cleaning and maintenance systems.
Surveyors found that kitchen vents, an ice machine, and equipment were not kept clean or in good repair, with black buildup on vents, rusted prep tables, missing food cart latches, and uncleanable surfaces. Staff were unclear about cleaning responsibilities, and cleaning schedules lacked assignments for key areas, potentially affecting nearly all residents receiving facility-prepared meals.
The facility did not maintain an effective pest control program, as evidenced by repeated observations and reports of flies, cockroaches, water bugs, and ants throughout all units. Both residents and staff confirmed ongoing pest issues, and pest control logs documented frequent sightings. Despite weekly visits from a pest control company, pests remained a persistent problem in common areas and resident rooms.
The facility did not report allegations of potential exploitation, abuse, and injuries of unknown origin to the State Agency within the required timeframe for four residents, including cases involving financial exploitation by a family member, a bruise of unknown origin, and a verbal altercation between two residents. Facility leadership confirmed awareness of the delays and acknowledged that reporting was not completed as required by policy.
The facility did not conduct timely or thorough investigations into allegations of financial exploitation and possible abuse involving two residents with severe cognitive impairment. In both cases, required steps such as interviewing involved staff and promptly initiating investigations were not followed, despite the facility's policy and awareness of the incidents.
A resident with multiple cardiac conditions was prescribed a Life Vest, but the care plan failed to address essential aspects such as device cleanliness, personal hygiene, alarm response, and physician notification, despite facility policy requiring these interventions. Staff interviews indicated unclear responsibility for care plan completion and missing documentation of these specific needs.
Surveyors found that multiple resident rooms had stained ceiling tiles, debris in heater vents, chipped paint, wall holes, rusted fixtures, and other cleanliness issues. The DM and LNHA confirmed these conditions did not provide a homelike environment, and the facility could not provide evidence of required weekly environmental rounds.
The facility failed to maintain sufficient CNA staffing levels, leading to long wait times for residents. Despite a staffing plan of 1 CNA to 8 residents during the day, the facility often had significantly fewer CNAs than required. This issue persisted over multiple weeks, with some shifts having less than half the needed staff. Interviews with the Staffing Coordinator and DON revealed awareness of the requirements, yet the facility consistently fell short of meeting them.
The facility failed to act on the consultant pharmacist's recommendations to discontinue unnecessary medications for two residents. Despite physician agreement, the medications remained active, indicating a breakdown in the medication regimen review process. Interviews with staff revealed that physicians are responsible for handling recommendations, but there was a lack of follow-through in discontinuing the medications.
Surveyors identified deficiencies in food handling and temperature monitoring at the facility. A dented can of mushrooms was improperly stored, and wet nesting of pans was observed, indicating sanitation issues. Additionally, freezer temperatures in the PAV1 and PAV3 pantries were not monitored due to the absence of thermometers, which staff were unaware were required.
The facility failed to maintain a clean and sanitary environment, with surveyors observing sticky floors, debris, and stains in rooms and hallways. A resident's IV pole was found covered with dried enteral feed formula over several days, despite housekeeping being responsible for cleaning. Interviews revealed discrepancies between the facility's cleaning policy and actual practices, with daily cleaning tasks not being adequately performed.
A facility failed to ensure the dignified transport of a non-ambulatory resident, as observed by a surveyor. A staff member was seen pulling a resident in a Geri-chair from behind, rather than pushing it forward, which did not promote the resident's dignity. The resident had severe cognitive impairment and physical impairments. The facility's policy emphasizes treating residents with dignity, but during an interview, the administration acknowledged the proper transport method should involve moving the resident forward.
A facility failed to implement a comprehensive care plan for a resident with a tracheostomy and chronic respiratory failure. Despite physician orders and documented needs for oxygen therapy and tracheostomy care, these were not included in the care plan. The RN/UM admitted responsibility for the oversight during a survey.
The facility failed to obtain physician orders for the hospital transfer of two residents, despite their medical conditions necessitating emergency care. One resident with Conversion Disorder was unresponsive, and another with spinal cord injury experienced shortness of breath. Both were transferred without documented physician orders, as confirmed by the DON.
A resident with a feeding tube did not have their piston set changed as per physician orders, which required a change every 24 hours. Despite documentation indicating compliance, the piston set had not been changed for two days. Interviews with the RN/UM and DON confirmed the importance of daily changes to prevent infection, highlighting a deficiency in infection control practices.
A resident using oxygen therapy at night did not have a required physician order, as observed by a surveyor. The facility's policy mandates a physician order for oxygen use, but the EMR lacked such an order for the resident, despite staff acknowledging the requirement. Interviews with staff confirmed the policy, yet the deficiency persisted.
A facility failed to complete the dialysis communication book for a resident with chronic kidney disease, who attended dialysis sessions three times a week. The facility's policy required a communication form to be filled out by the facility nurse and the dialysis center, but the surveyor found that on multiple occasions, either the facility or the dialysis center did not complete their respective portions. The resident's LPN and RN/UM confirmed the incomplete forms, and the DON stated that nurses were responsible for ensuring the form was completed and reviewed.
The facility failed to manage medications properly, resulting in expired and discontinued medications being administered and stored. An LPN administered expired pantoprazole to a resident, and pre-signed a narcotic count record, violating policy. Additionally, expired Fentanyl patches were found in the automated dispensing system, despite daily checks. The DON and Consultant Pharmacist confirmed these practices were against protocol.
The facility's QAPI committee failed to effectively monitor and address expired medications on medication carts. Despite identifying the issue in February 2024, the facility did not implement a systematic process for checking carts three times weekly. The QAPI plan outlined goals and responsible team members, but no data collection forms were available to demonstrate compliance. The DON admitted the plan did not work, and the facility could not provide data to support the reported 77% compliance rate.
The facility failed to properly store medical supplies and ensure laundry staff used appropriate PPE. Medical supplies were found stored under a sink, risking contamination, and a bag of IV fluid was improperly stored. Laundry staff did not wear required PPE while handling soiled laundry, and hand hygiene was not performed. The Infection Preventionist and Director of Environmental Services were unaware of relevant policies, contributing to these deficiencies.
Failure to Offer Recommended Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer three residents, R80, R17, and R86, or their representatives, the opportunity to receive pneumococcal vaccination in accordance with nationally recognized standards. Review of R80’s EMR showed admission to the facility on 02/21/22, with the resident over age 65 at admission and later receiving Pneumovax 23 on 09/05/23; there was no evidence in the clinical record that the resident or representative was offered PCV20 or PCV21. Review of R17’s EMR showed admission on 11/13/19, with the resident turning [AGE] years old while living at the facility and receiving Pneumovax 23 on 09/05/23; there was no evidence in the record that the resident or representative was offered PCV20 or PCV21. Review of R86’s EMR showed admission on 02/26/21, with the resident turning [AGE] years old while living at the facility and receiving Pneumovax 23 on 10/04/23; there was no evidence in the record that the resident or representative was offered PCV20 or PCV21. During interview on 01/15/26, the Regional Nurse Consultant and Infection Preventionist reviewed the records for R20, R17, and R86 and verified that the three residents had received only Pneumovax 23 and did not receive PCV13. Review of the facility policy showed it did not reflect current CDC recommendations, and the CDC PneumoRecs VaxAdvisor guidance reviewed on 01/15/25 stated that adults 50 years or older who have never received a pneumococcal conjugate vaccine should receive PCV15, PCV20, or PCV21, and that adults 65 years or older who previously received PCV13 and PPSV23 at or after age [AGE] years have the option to receive PCV20 or PCV21.
Resident Not Included in Care Planning Process
Penalty
Summary
The facility failed to ensure that one resident was afforded the right to participate in the development and implementation of the person-centered plan of care. Review of the resident’s EMR showed admission to the facility on 11/13/19, and a social services progress note dated 05/23/25 documented that the resident attended a care conference. However, there was no further evidence in the clinical record that the resident was invited to subsequent care conferences after that date. Review of the resident’s quarterly MDS with an ARD of 11/07/25 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Facility documents titled IDT Meeting Information dated 08/20/25 and 11/20/25 did not show that the resident was invited to the care conferences. During interview, the resident stated he/she had not been invited to care plan meetings for a while. The SSD stated there had been a period when the EMR was not working and paper copies were used for care conferences, and confirmed there was no evidence on the IDT Meeting documents that the resident was invited or participated in the care conference.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect one resident from resident-to-resident abuse when a cognitively impaired resident struck another resident in the face after the other resident touched the assailant’s shoulder while they were seated together at the nurses’ station. The assaulted resident, who had diagnoses including muscle wasting and atrophy, an anxiety disorder, and major depressive disorder, was moderately cognitively impaired with a BIMS score of 12 out of 15. The resident who struck the other resident had diagnoses including schizoaffective disorder, bipolar type, recurrent depressive disorder, and anxiety disorder, and was significantly cognitively impaired with a BIMS score of 2 out of 15. The incident investigation documented that the strike caused a swollen upper lip and knocked out two front teeth. The residents were immediately separated, and the witness CNA reported that the assailant said he/she thought the other resident had hit him/her first and then hit back. Interviews with the residents and staff reflected that neither resident had prior behavior concerns before the incident, and the facility’s abuse policy stated residents would be protected from abuse, neglect, mistreatment, or misappropriation of property in accordance with state and federal regulations.
Failure to Arrange Cataract Surgery Appointment
Penalty
Summary
The facility failed to ensure that one of one resident reviewed for vision services, R41, had an appointment made for cataract removal after an optometrist wrote an order on 05/27/25 to schedule cataract surgery at an outside facility. R41’s quarterly MDS showed a BIMS score of 14 out of 15, indicating the resident was cognitively intact. Progress notes documented that the Unit Secretary called an outside facility on 06/01/25 to schedule the surgery, but the appointment was denied because R41 weighed 374 pounds. The record contained no evidence of any additional attempts to find another outside facility that could accommodate the resident’s cataract surgery. During interview, R41 stated he/she could not see and needed to see the doctor. An LPN stated calls had been made to other facilities after the denial, but also stated that the Unit Secretary made the calls and documentation was not available. The DON stated he/she was unaware that an appointment was needed for R41.
Failure to Honor Resident Rights to Outdoor Access and Self-Determination in Smoking Practices
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence, self-determination, and communication by restricting access to outdoor areas and limiting smoking opportunities for residents, including those who were cognitively intact and assessed as safe to smoke without supervision. Facility policy required that residents be informed of smoking policies and that their preferences and abilities be assessed, but in practice, residents were only permitted to smoke three times daily for twenty minutes each, with a maximum of two cigarettes per session. These sessions were strictly supervised by activity staff, and the outdoor patio area was locked outside of these designated times, preventing residents from accessing the area at their leisure. Multiple residents, both smokers and non-smokers, expressed dissatisfaction with these restrictions. Cognitively intact residents who were assessed as not requiring supervision for smoking reported that they would like more frequent access to smoke breaks, the ability to smoke more cigarettes per session, and the opportunity to smoke after dinner or before bed. Non-smoking residents were also limited in their access to the outdoor patio, only being allowed outside twice daily during scheduled activities, with no option to go out at other times. Staff interviews confirmed that the patio was kept locked and that residents could only go outside when accompanied by staff, citing safety concerns such as the risk of falls. Review of facility records and interviews revealed that these restrictions were not individualized based on resident assessments or preferences, but rather applied uniformly to all residents regardless of their cognitive status or ability to safely access the outdoor area. The activity calendar did not include any outdoor activities, further limiting residents' opportunities for outdoor access. The facility's actions were inconsistent with its own policies and regulatory requirements to promote resident rights, dignity, and quality of life.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a clean, safe, and homelike environment across all three floors. Observations included broken room number signs, unidentified spills and unclean walls, sticky and grimy floors, holes in walls, damaged furniture, and missing or damaged window screens. Equipment such as wheelchairs, electric wheelchairs, and Geri chairs were found to be dirty, with worn or missing padding and exposed hardware. Air conditioning units were noted to be rusty, broken, or emitting little cool air, and ceiling vents and door frames were dirty, rusty, or missing covers. Shower rooms lacked proper cleaning, with dirty tables and heavy grime buildup, and some areas had no vent covers. Trash and debris were observed throughout the facility, and there were strong urine odors in certain hallways. Interviews with residents and staff confirmed these environmental concerns. Residents reported that equipment, bathrooms, and shower rooms were dirty, walls needed cleaning, and there were issues with pests such as flies and ants. Some residents noted that floors were often sticky and that window screens were broken. Staff, including the Environmental Director and Maintenance Director, acknowledged the lack of established cleaning systems and confirmed the presence of the documented issues during facility tours. The Environmental Director stated that prior to their arrival, there was no system in place for cleaning rooms, floors, or halls, and the Maintenance Director, new to the facility, recognized the need for improvements. Review of facility policies and logs revealed that while there were policies for maintenance rounds and cleaning, implementation was lacking. Cleaning schedules and logs were either undated, lacked specificity, or indicated infrequent cleaning (e.g., wheelchairs cleaned every three months). Maintenance logs did not address the specific issues observed. The facility's failure to adhere to its own policies and to maintain a sanitary, comfortable, and homelike environment resulted in the cited deficiencies.
Deficient Kitchen Cleanliness and Equipment Maintenance
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's kitchen related to cleanliness and equipment maintenance. During an inspection, it was observed that two out of three insulated food carts failed to latch properly, and a third cart was missing a latch on one door. Several ceiling vents, including those near the prep table and above the oven/stove, had a heavy buildup of a black substance. The vent on the outside of the ice machine also had a black substance that transferred onto the surveyor's finger when touched. The tray line table was missing rollers and had a piece of cardboard taped to its side with tattered duct tape, creating an uncleanable surface. Additionally, the prep table behind the plate warmer had significant rust on its legs, shelf, and edges, and a portable stand fan near the oven was found without a front cover, with exposed blades covered in dust and grime. Interviews with the Dietary Director and the Regional Food Service Director revealed uncertainty regarding responsibility for cleaning the vents and maintaining equipment. Review of the cleaning schedule showed no assigned tasks for cleaning the vents, ice machine, or floor fan. There was no evidence that the need for repairs to the insulated food carts had been identified prior to the survey. Furthermore, a policy and procedure for kitchen cleaning was not provided before the survey exit. These failures had the potential to affect 149 of 153 residents who received meals prepared in the facility kitchen.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in the presence of flies, cockroaches, water bugs, and ants throughout the building. Pest control logs indicated repeated reports of flies and cockroaches/water bugs on all three units over a three-month period. During multiple facility tours, surveyors observed numerous flies on all floors and a large dead roach in a resident room entry. Residents unanimously reported ongoing issues with flies and water bugs in both common areas and individual rooms, with some also noting the presence of ants around the nurse's desk. Staff interviews confirmed recent sightings of these pests and acknowledged that pest sightings were documented in pest control books on each unit. The Director of Housekeeping and Laundry, along with the President of Environmental Services, confirmed the ongoing pest issues and stated that the pest control company visited weekly, basing their services on reported sightings. Despite these measures, pests continued to be observed by both staff and residents, and the problem was described as persistent and bothersome. The Administrator stated her expectation that the facility should be free of pests, but the ongoing presence of flies, water bugs, and ants indicated that the pest control program was not effective in preventing or addressing infestations.
Failure to Timely Report Allegations of Abuse, Neglect, and Exploitation
Penalty
Summary
The facility failed to ensure timely reporting of allegations of potential exploitation and/or abuse to the State Agency for four residents. According to the facility's policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are to be reported immediately, but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. However, the facility did not adhere to this policy in several instances, as evidenced by record reviews and staff interviews. For one resident with dementia and a history of falls, concerns regarding potential financial exploitation by family members were known to the facility since June, but were not reported to the State Agency or local police until months later, during the surveyors' investigation. The resident was severely cognitively impaired and unable to manage her own finances, with her responsible party refusing to provide information about the resident's assets. Multiple attempts were made by the facility to obtain this information, and involuntary discharge notices were issued due to non-payment, but the potential exploitation was not reported until prompted by surveyors. In another case, a resident with severe cognitive impairment was found with a bruise of unknown origin. The injury was identified and documented, but the incident was not reported to the State Agency until almost 24 hours later, exceeding the required two-hour reporting window. Additionally, a verbal altercation between two severely cognitively impaired residents was not reported to the State Agency until nearly 12 hours after the incident. In all cases, facility leadership confirmed that the incidents were reported late and acknowledged that they should have been reported within the required timeframe.
Failure to Investigate Allegations of Exploitation and Abuse
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of potential exploitation and abuse involving two residents. For the first resident, who had dementia and a history of falls and was severely cognitively impaired, concerns about possible financial exploitation by a family member were known to the Administrator as early as June. Despite repeated attempts by staff to contact the responsible party and ongoing concerns about the resident's assets, no investigation was initiated until surveyors requested information in September. The facility's own policy required prompt and comprehensive investigation of such allegations, but this was not followed. In the second case, another resident with dementia, cerebral ischemia, and COPD, and who was also severely cognitively impaired, was found with bruising and discoloration to the right hand after an incident involving a CNA. The progress notes indicated that the resident had refused care and allegedly swung a backscratcher at the CNA, after which the CNA removed the object from the resident's hand. The facility's investigation into the injury did not include interviews with staff present during the incident, as required by policy, to determine whether abuse had occurred. Interviews with facility leadership confirmed that the required investigations were not conducted in either case. The President of Clinical and the Regional Nurse Consultant acknowledged that both the potential financial exploitation and the injury of unknown origin should have been thoroughly investigated according to facility policy, but this did not occur until prompted by surveyors.
Failure to Develop Comprehensive Care Plan for Resident Using Life Vest
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed a Life Vest, a wearable defibrillator, as part of their treatment for multiple cardiac conditions including hemiplegia, hypertensive heart disease with heart failure, chronic atrial fibrillation, and chronic diastolic congestive heart failure. Although physician orders specified daily battery changes and monitoring of the device for function and placement, the care plan only addressed general cardiovascular status and dietary recommendations, omitting critical aspects related to the Life Vest. Specifically, the care plan did not include interventions for maintaining the cleanliness of the Life Vest, ensuring personal hygiene while using the device, responding to device alarms, or instructions on when to notify the physician. Review of facility policy indicated these elements were required, including daily inspection for cleanliness and fit, assistance with hygiene, and protocols for responding to both non-emergency and emergency alarms. Interviews with staff revealed a lack of clarity regarding responsibility for completing the care plan and an absence of documentation addressing these specific needs.
Failure to Maintain Clean and Homelike Environment in Resident Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean and homelike environment for residents on two of three units, specifically Pavilion 2 and Pavilion 3. During tours of these units, multiple resident rooms were found with brown stains on ceiling tiles, a build-up of dust and unknown debris in heater vents, chipped paint on walls and heaters, holes in the walls, rust on electrical outlet covers, rust spots on bathroom floors, and tape around heaters. These environmental deficiencies were directly observed by surveyors during their inspection. Interviews with the Director of Maintenance (DM) revealed that maintenance staff were responsible for addressing these issues, and that environmental rounds were supposed to be conducted weekly by the DM, Housekeeping Director (HD), nursing staff, and the Licensed Nursing Home Administrator (LNHA). However, the DM stated he was not aware of the specific deficiencies prior to the survey, and the facility was unable to provide evidence that weekly environmental rounds had been completed, aside from work order sheets. The DM and LNHA acknowledged the findings and confirmed that these conditions did not create a homelike environment for residents.
Deficient CNA Staffing Levels
Penalty
Summary
The facility failed to ensure sufficient nursing staff on a 24-hour basis to meet the needs of residents, as evidenced by multiple deficiencies in Certified Nurse Aide (CNA) staffing levels. The facility's assessment outlined a staffing approach of 1 CNA to 8 residents during the day, 1 to 10 in the evening, and 1 to 14 at night. However, during a resident council meeting, residents reported long wait times due to understaffing, particularly at night. The New Jersey Department of Health's Nurse Staffing Report confirmed these deficiencies, showing that the facility consistently failed to meet the required CNA staffing levels across various shifts and dates. The report detailed specific instances where the facility provided significantly fewer CNAs than required. For example, on several occasions, the facility had only 12 to 16 CNAs for 160 to 170 residents during the day shift, where at least 20 to 21 CNAs were needed. This pattern of understaffing was observed over multiple weeks, with some shifts having less than half the required number of CNAs. Additionally, the facility was also deficient in total staff for residents on some overnight and evening shifts, further exacerbating the issue of inadequate care. Interviews with the facility's Staffing Coordinator and Director of Nursing revealed an awareness of the staffing requirements, yet the facility struggled to meet these standards consistently. The Staffing Coordinator believed they were meeting the minimum requirements most of the time, despite evidence to the contrary. The Director of Nursing provided details on the staffing pattern for nurses across different pavilions, which also indicated a shortfall in meeting the necessary staffing levels to ensure adequate care for all residents.
Failure to Implement Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to consistently and timely follow through on recommendations made by the consultant pharmacist during the monthly medication regimen review for two residents. The consultant pharmacist recommended discontinuing certain medications that had not been used for over 60 days, but these recommendations were not acted upon by the attending physicians, despite their agreement to do so. This deficiency was identified for two residents who were reviewed for unnecessary medications. For one resident, the consultant pharmacist recommended discontinuing the PRN Dicyclomine medication, as it had not been used for over 60 days. The attending physician agreed with this recommendation and signed off on it, but the medication order remained active, and the resident's medication administration record showed no discontinuation of the drug. Similarly, for another resident, the consultant pharmacist recommended re-evaluating the need for Lasix, a diuretic, as the resident had been on it since the previous year. The attending physician agreed to this recommendation, but there was no documentation in the resident's progress notes indicating that the medication was discontinued. Interviews with facility staff, including a Licensed Practical Nurse/Unit Manager and the Director of Nursing, revealed a breakdown in the process of implementing the consultant pharmacist's recommendations. The staff indicated that while physicians are responsible for handling and agreeing to the recommendations, there was a lack of follow-through in discontinuing the medications as agreed. The Director of Nursing acknowledged the breakdown in the medication regimen review process and the need for improvement.
Deficiencies in Food Handling and Temperature Monitoring
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed by surveyors. In the dry storage room, a can of mushrooms with a significant dent on the seam was found, which was then removed to the designated dented can area by the Food Service Director (FSD). Additionally, a stack of five deep/full pans was found wet nested, with a clear, watery substance on the bottom surface of the pans, indicating improper drying and storage. The FSD removed these pans for rewashing and sanitizing. Furthermore, the facility did not monitor freezer temperatures in the pantries, as required. In the PAV1 pantry, the temperature log only recorded refrigerator temperatures, and there was no internal thermometer in the freezer. The Unit Manager/Licensed Practical Nurse (UM/LPN) was unaware of the need for a thermometer and monitoring of freezer temperatures. Similarly, in the PAV3 pantry, no freezer temperatures were recorded, and no internal thermometer was present. The LPN/UM acknowledged the oversight and the need for a thermometer.
Deficiencies in Facility Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by observations on two of its units, Pavilion 2 and Pavilion 3. During the initial and subsequent tours, surveyors noted several deficiencies, including sticky floors, debris, hair knots, dark marks, and stains in various rooms and hallways. A family member reported that the rooms were not being cleaned properly, with floors only being mopped without prior sweeping, and toilets not being cleaned. Interviews with the Director of Environmental Services and Laundry (DEVS) and housekeeping staff revealed discrepancies between the facility's cleaning policy and actual practices, with daily cleaning tasks not being adequately performed. Additionally, the facility failed to properly clean and maintain IV poles, as observed in the case of a resident who was receiving tube feeding. The IV pole base was consistently found to be covered with a dried tan/brown substance resembling enteral feed formula over multiple days. Despite the facility's policy that housekeeping staff are responsible for cleaning IV poles weekly or as needed, the IV pole in the resident's room remained uncleaned for several days. Interviews with housekeeping staff and the DEVS confirmed that the responsibility for cleaning IV poles lay with housekeeping, yet the task was not completed. The facility's failure to adhere to its cleaning policies and maintain a sanitary environment was confirmed through interviews with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). They acknowledged that housekeeping and environmental services were responsible for cleaning IV poles and addressing spills. The report highlights significant lapses in the facility's cleaning protocols, contributing to an unsanitary environment for residents.
Failure to Ensure Dignified Transport of Non-Ambulatory Resident
Penalty
Summary
The facility failed to ensure the dignified transport of a non-ambulatory resident, which was identified during a survey. A surveyor observed a staff member transporting a resident in a Geri-chair by pulling it from behind, rather than pushing it forward, as they moved from the dining/activity room past the nursing station. This method of transport did not promote the dignity and respect of the resident, as it is generally expected that residents should be transported facing forward to maintain their dignity and allow them to see where they are going. The resident involved had severe cognitive impairment, as indicated by a Brief Interview for Mental Status score of 3/15, and had impairments in both the lower and upper extremities. The facility's policy on resident rights emphasizes the importance of treating all residents with dignity and respect, regardless of their condition. However, during an interview with the facility administration, including the DON and LNHA, it was acknowledged that the proper method of transport should involve moving the resident forward, aligning with the direction of movement for both the staff and the resident.
Failure to Implement Comprehensive Respiratory Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with significant respiratory needs. The resident, who had a tracheostomy and required continuous oxygen therapy, was observed without a care plan addressing their respiratory care. Despite having physician orders for tracheostomy care and the need for oxygen therapy, suctioning, and tracheostomy care documented in the Minimum Data Set, these were not reflected in the resident's care plan. During an interview, the Registered Nurse/Unit Manager acknowledged the absence of a care plan for the resident's respiratory care, stating it was her responsibility to ensure one was in place. This oversight was identified during a survey, highlighting a deficiency in meeting the resident's medical and nursing needs through a comprehensive care plan.
Failure to Obtain Physician Orders for Hospital Transfers
Penalty
Summary
The facility failed to ensure that a physician order was obtained for the transfer of two residents to the hospital, which is a requirement according to the facility's policy. Resident #126, who was admitted with a diagnosis of Conversion Disorder with Seizures or Convulsions, was found unresponsive with eyes rolled up, prompting a call to 911 and subsequent transfer to the hospital. However, a review of the Electronic Medical Record (EMR) revealed that there was no physician order documented for this transfer. The Director of Nursing (DON) confirmed during an interview that an order should have been in place. Similarly, Resident #137, who had diagnoses including injury of the cervical spinal cord, muscle weakness, and difficulty walking, was observed with shortness of breath and pale skin. The Nurse Practitioner (NP) was contacted and ordered the resident to be sent to the hospital via 911. Despite this, the Medication Review Report for August 2024 did not show a physician's order for the transfer. The DON acknowledged the absence of the required order in the resident's medical record, confirming the deficiency.
Failure to Change Piston Set for Resident with Feeding Tube
Penalty
Summary
The facility failed to adhere to physician orders regarding the timely change of a piston set for a resident with a feeding tube. The resident, who was admitted with conditions including Multiple Sclerosis, a Gastrostomy (G Tube), and Dysphagia, required the piston set to be changed every 24 hours as per the physician's order. However, during an observation on August 5, 2024, it was noted that the piston set had not been changed since August 3, 2024, despite documentation indicating otherwise. This discrepancy was confirmed through interviews with the Registered Nurse/Unit Manager and the Director of Nursing, who both acknowledged the importance of changing the piston set daily to prevent infection. The facility's policy on enteral tubes, revised in June 2024, mandates that the syringe and bag be changed every 24 hours to maintain infection control. The failure to change the piston set as required was documented in the Treatment Administration Record, where signatures falsely indicated compliance with the order. The Registered Nurse/Unit Manager and the Director of Nursing both emphasized the risk of introducing bacteria into the resident's gastrointestinal system if the piston set is not changed as prescribed. This oversight in following the physician's order and facility policy resulted in a deficiency related to infection control practices.
Lack of Physician Order for Oxygen Use
Penalty
Summary
The facility failed to ensure that a resident using oxygen therapy at night had a physician order, which is a requirement according to the facility's policy. During an initial tour, a surveyor observed oxygen tubing next to the resident's bed, which was not dated, and there was no oxygen sign outside the room. The resident confirmed using oxygen at night. A review of the Electronic Medical Record (EMR) showed that the resident was admitted with diagnoses including hypertensive heart disease and had been using oxygen since admission. However, the Order Summary Report did not include a physician order for oxygen use at bedtime. Interviews with facility staff, including an LPN, RN/UM, and the Director of Nursing, confirmed that a physician order is required for oxygen use, except in emergencies. Despite this, the RN/UM acknowledged the absence of a physician order for the resident's oxygen use, even though the resident reported using it nightly and nurses documented pulse oximetry readings while on oxygen. The facility's policy and staff statements highlighted the need for a physician order, but this was not adhered to in the case of the resident in question.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to complete the dialysis communication book for a resident who required dialysis services. The resident, who had chronic kidney disease and was dependent on renal dialysis, attended dialysis sessions three times a week. The facility's policy required a communication form to be filled out by the facility nurse with the resident's vital signs and by the dialysis center with treatment details. However, the surveyor found that on multiple occasions, either the facility or the dialysis center did not complete their respective portions of the communication form. The resident's Licensed Practical Nurse (LPN) and Registered Nurse Unit Manager (RN/UM) confirmed the incomplete forms, acknowledging that the communication book was not consistently filled out as required. The Director of Nursing (DON) stated that the nurses were responsible for ensuring the form was completed and reviewed upon the resident's return from dialysis. Despite this, the surveyor identified that the communication process between the facility and the dialysis center was not adequately maintained, leading to incomplete documentation for the resident's dialysis care.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper management of medications, leading to several deficiencies. During a medication cart inspection, it was discovered that a discontinued and expired medication, pantoprazole, was still present in the active inventory and had been administered to a resident. The medication was ordered for the treatment of GERD and had been discontinued months prior, yet remained in the cart until the surveyor's inquiry. The Licensed Practical Nurse (LPN) involved admitted to not checking the expiration date, and the Consultant Pharmacist and Director of Nursing (DON) confirmed that staff should verify expiration dates before administration. Additionally, the facility did not maintain accurate accountability for controlled substances. The surveyor found that an LPN had pre-signed the Narcotic Count Record for a shift he had not yet completed, which is against the facility's policy. The purpose of the narcotic count is to ensure that both incoming and outgoing nurses agree on the count's accuracy, and pre-signing undermines this process. The DON and Consultant Pharmacist both emphasized that pre-signing is unacceptable and that the count should be verified at the time of the shift change. Furthermore, expired controlled medications were not removed from the automated medication dispensing system. During a cycle count, it was found that expired Fentanyl patches were still present in the system, despite daily cycle counts being performed by the Registered Nurse Supervisor and Infection Preventionist. The DON acknowledged that the expired medications should have been identified and removed during these counts, and the Consultant Pharmacist reiterated that expired medications should not be present in the system.
Failure in QAPI Process for Monitoring Expired Medications
Penalty
Summary
The facility's Quality Assessment and Performance Improvement (QAPI) committee failed to effectively utilize the Facility Performance Improvement Plan (PIP) to monitor and address the issue of expired medications on medication carts. Despite identifying expired medications as a major concern in February 2024 through pharmacy reports, the facility did not implement a systematic process to measure and utilize data for checking medication carts three times weekly. The QAPI plan outlined goals such as removing expired medications and educating LPNs on checking carts, with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and LPNs identified as responsible team members. However, the plan's implementation was ongoing, and no data collection forms were available to demonstrate compliance or progress. During the survey, it was revealed that the facility did not have any data collected for the expired medication QAPI plan for February or April 2024. The DON admitted to the surveyors that the QAPI plan did not work, and they were in the process of developing a new one. The facility also could not provide data to support the reported 77% compliance rate mentioned in the April 2024 QAPI plan, with the DON suggesting that the data might have come from the monthly consultant pharmacist visit. This lack of data collection and monitoring indicates a failure in the facility's QAPI process to address and rectify the issue of expired medications effectively.
Infection Control Deficiencies in Medical Supply Storage and Laundry Handling
Penalty
Summary
The facility was found to have deficiencies in the storage and maintenance of medical supplies and the use of personal protective equipment (PPE) by laundry staff. During an inspection of the Pavilion Three Medication Storage Room, it was observed that several medical supplies, including enema kits, heel booties, and wound treatment supplies, were improperly stored beneath a handwashing sink. The Licensed Practical Nurse Unit Manager (LPN/UM) was unaware of the supplies being stored there and acknowledged the risk of contamination. Similarly, in the Pavilion Two Medication Room, a bag of intravenous fluid solution was found with its packaging previously opened, which could compromise its effectiveness. The Infection Preventionist (IP) and Central Supply Director (CSD) confirmed that storing items under the sink was against facility rules due to contamination risks, and the Director of Nursing (DON) emphasized the unsanitary nature of such storage practices. In the laundry area, a staff member was observed not wearing the required PPE while handling soiled laundry. The staff member wore a surgical mask improperly and gloves but did not wear an apron or gown as required by the facility's Linen Handling Policy. The staff member admitted to not wearing the apron initially and failed to perform hand hygiene after removing gloves. The Infection Preventionist was not familiar with the laundry policy regarding soiled linens, and the Director of Environmental Services and Laundry (DEVS) stated that staff should wear gowns, gloves, and masks, although he had never seen anyone wear an apron. The facility's failure to adhere to proper infection prevention and control practices was evident in both the medication storage and laundry handling processes. The lack of awareness and enforcement of policies by staff and management contributed to these deficiencies, posing potential risks of contamination and infection.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pennsauken
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| United Methodist Communities At Collingswood | 0.7 mi | ★★★★★ | 4 | 0 |
| Aristacare At Cherry Hill | 1.8 mi | ★★★★★ | 21 | 0 |
| Majestic Center For Rehab & Sub-acute Care | 2.6 mi | ★★★★★ | 3 | 0 |
| Premier Cadbury Of Cherry Hill | 2.6 mi | ★★★★★ | 27 | 0 |
| Abigail House For Nursing & Rehabilitation | 2.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.