River's Edge Rehabilitation & Healthcare Center

Inspectors wroteBased on review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to ensure one resident was allowed to exercise their right to make choices regarding daily activities for one of four residents reviewed. (Resident R1)

Inspectors wroteBased on observation and interview with staff, it was determined the facility failed to ensure the dish machine was maintained in safe and functional operating condition.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure residents' advance directives and physician orders for Life-Sustaining Treatment (POLST) were followed according to the residents' expressed wishes for 2 of 24 residents reviewed (Resident R5 and R13).

Inspectors wroteBased on observations, and staff interview, it was determined that the facility failed to ensure that the grievance forms were available and that residents had the right to file an anonymous grievance for two of two nursing units (first and second floor).

Inspectors wroteBased on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to ensure that the physician documented either a 14-day stop date or a clinical justification for the continued use of PRN (as needed) psychotropic (alters mood, perception, and behavior) medication for two of four residents reviewed (Residents R7 and R5).

Inspectors wroteBased on review of clinical records, review of facility policy and interview with residents and staff, it was determined that the facility failed to develop a person-centered resident care plan for two of twenty-four residents reviewed (Resident R5 and Resident R25). Findings Include: Review of facility policy titled Care plan dated September 2024. Under policy states It is the policy of the facility to participate in an individual, interdisciplinary plan of care for all residents. Under procedure states the plan of care shall be individualized to and based upon the assessment and diagnosis of a resident, To provide a comprehensive health care environment, all staff members should consider interdisciplinary collaboration to establish goals and appropriate interventions, and ongoing evaluations and revisions to resident care. [...]

Inspectors wroteBased on a review of the clinical record, facility documentation, observations, and interviews with staff and residents, it was determined that the facility failed to provide Activities of Daily Living (ADL) assistance for one of the two residents reviewed (Resident R9).

Inspectors wroteBased on direct observation, clinical record review, and interviews with staff, it was determined that the facility failed to ensure enteral feedings were administered and monitored according to professional standards of practice, specifically related to labeling, for one of two resident's reviewed fed via enteral feeding (Resident R6).

Inspectors wroteBased on review of clinical records and interview with staff, it was determined that the facility failed to ensure pain medication was administered in accordance with the physician's order for one of four residents reviewed for pain management (Resident R33). Findings Include: Review of Resident R33's clinical record revealed Resident R33 was admitted to the facility on [DATE] with a diagnosis of local infection of the skin and subcutaneous tissue, polyneuropathy (condition that damages multiple peripheral nerves in the body), and anxiety disorder. Review of Resident R33's clinical record revealed physician's order, dated February 16, 2026, for Oxycodone 5 milligrams give 5 mg by mouth every 4 hours as needed for pain 6-10. [...]

Inspectors wroteBased on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of one residents sampled for post-traumatic stress disorder (PTSD). (Resident R14).

Inspectors wroteBased on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for six of 24 residents reviewed (Residents R3, R8, R12, R44, R80, and R112).

Inspectors wroteBased on review of facility assessment and staff interview, it was determined that the facility failed to ensure the direct care staff and input from residents, resident representatives, and/or family members was included when conducting the facility assessment.

Inspectors wroteBased on a review of clinical records, facility documents, and staff interview, it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not) for three of five residents reviewed (Resident R135, R126, R7).

Inspectors wroteBased on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for three residents reviewed who had a indwelling Foley catheter, wound and internal feeding tube. (Residents R6, R91, and R108). Based on a review of the facility's Infection Control requirements Influenza Vaccine for Unvaccinated Healthcare workers to be wearing a mask, the facility failed to ensure that unvaccinated healthcare workers are wearing a mask. Specifically, vaccinated record for one Licensed Practical Nurse, who refused the Influenza Vaccine was not wearing a mask. Findings Include: According to the facility policy titled Influenza Vaccine (reviewed December,2025) number 11, the use of source control for unvaccinated health care workers will be based on state guidelines or outbreak status. [...]

Inspectors wroteBased on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.

Inspectors wroteBased on staff interview and review of clinical records, it was determined that the facility failed to ensure that care plan meetings were held for one of 24 residents reviewed. (Resident R55)

Inspectors wroteBased on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer to the hospital in a timely manner, in writing and in a language and manner they understood for two of 24 residents reviewed for hospitalizations (Residents R31 and R102). Findings Include: Review of nursing notes for Resident R31 dated November 20, 2024, at 11 p.m. revealed that the resident was admitted to the hospital with diagnosis of hematoma of the left kidney and abdominal pain. Further review revealed a note, dated on October 25, 2024, at 2:42 p.m. revealed that Resident R31 was discharged home. Review of nursing notes for Residents R102 dated March 20, 2025, at 4:35 p.m. [...]

Inspectors wroteBased on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement treatment and services for incontinence management for one of 24 residents reviewed.(Resident R11).

Inspectors wroteBased on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for two of four residents reviewed for nutrition (Resident R35). Findings Include: Review of facility policy titled, Weight Loss indicated that any resident displaying a significant change in weight of greater than or equal to 5% gain/loss in one month will be reweighed. Review of facility policy Supplementation dated January 2025 indicated that if an increase in caloric or protein needs are identified, the Dietitian will determine which supplements are appropriate to meet the specific resident's needs. [...]

Inspectors wroteBased on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 24 residents reviewed (Resident R84). Findings Include: Reviewed facility dementia policy title Care Plan dated in September 2024 states that the plan of care shall be individualized to and based upon, the assessment and diagnosis of a resident. Review of the admission sheet of Resident R84, revealed that Resident R84 was admitted to the facility on [DATE], with the diagnosis of Dementia (Dementia is not a specific disease but is rather a general term for the impaired ability to remember think, or make decisions that interferes with doing everyday activities). [...]

Inspectors wroteBased on staff interviews and clinical record reviews, it was determined that the facility failed to ensure that mattresses and bed frames that were purchased separately were compatible with each other for one of 24 residents reviewed (Resident R99).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to follow physician orders related to medication administration for two of 13 residents reviewed (Residents R3 and CL2). Findings Include: Facility Policy titled, Medication Administration Policy updated, January 2024 revealed under procedures J. Medication Administration 8. Ensure that the customer swallows all the medication(s). Medication Times BID (Twice a Day) = 0900-1700, TID (Three Times a Day) 0900-1300-2100, QID (Fourt Times a Day) =0900-1300-1700-2100; Before Meals=0600-11:00-1630, After Meals= 0900-1300-1800. [...]

Inspectors wroteBased on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that residents and /or their responsible parties were provided with the opportunity to participate in their care plan meetings for 4 out of 27 residents reviewed (Residents R64, R54, R85 and R69).

Inspectors wroteBased on staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that a physician was notified of a resident's refusal to take prescribed medication for 1 out of 27 residents reviewed (Resident R39).

Inspectors wroteBased on interviews, review of facility policy, review of clinical records and facility reports, it was determined that the facility failed to ensure a complete and through investigation for bruises of unknown origin for 1 out of 27 residents reviewed (Resident R69).

Inspectors wroteBased on review of facility documentation, clinical record reviews, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as required for four of four records reviewed related to hospital transfers (Residents R86, R23, R83 and R92).

Inspectors wroteBased on observation, staff interviews, review of resident records and facility policy, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 27 resident records reviewed (Residents R40, R62, and R65).

Inspectors wroteBased on observations, review of clinical records, and staff interviews, it was determined that the facility failed to ensure a physician order for neurology was followed for one of 27 residents reviewed (Resident R62).

Inspectors wroteBased on review of facility policy, observations, record review, and staff interviews, it was determined that the facility failed to provide respiratory care services consistent with professional standards of practice for three of 27 residents reviewed, (Residents R40, Resident R62, Resident R65). Findings Include: Review of facility policy for Oxygen Administration revised in January 2024 indicates the purpose of this policy it to safely administer oxygen to the resident. Nursing staff will be responsible the correct administration of oxygen. The same policy states when a concentrator is used to wash the filter weekly. Review of Resident R40's physician order dated December 11, 2023, instructed to administer oxygen at 2 liters a minute via nasal cannula as needed for shortness of breath. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure the accurate acquiring, receiving, and administration of medications to meet the needs of each resident for one of 27 residents reviewed (Resident R56). Findings Include: Review of facility policy Medication/Order Availability (undated) revealed all residents should have medications/orders administered as ordered. Per review of facility policy, in the case a medication/supply is not available, and to ensure comparable alternative is provided, staff should implement the following procedures: 1. Medication/orders are to be administered per MD order 2. If medication/supply is not available in the facility, MD is to be notified 3. Resident's plan of care is to be reviewed and suggested alternative ordered and provided. 4. [...]

Inspectors wroteBased on review of clinical records, and staff interview, it was determined that the facility failed to obtain laboratory services to meet the needs of one resident's digoxin levels per physician orders of 27 residents reviewed (Resident R55).

Inspectors wroteBased on review of clinical records, review of facility policies and procedures and interviews with staff, it was determined that the facility failed to promptly notify a resident's representative of a new pressure ulcer for one of three residents reviewed for pressure ulcer prevention. (Resident R1).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet care needs for one of three residents reviewed. (Resident R1)

Inspectors wroteBased on the review of clinical records, and interview with staff and residents, it was determined that the facility failed to develop and implement an effective discharge planning process including the resident's discharge goals and information to the resident's representative of the final plan upon resident's discharge for one of three resident reviewed. (Resident R1) Findings Include: Review of Resident R1's Minimum Data Set assessment (MDS- assessment of a resident's abilities and care needs) dated October 17, 2023, identified that the resident did not have a pressure ulcer/injury (Injury to skin and underlying tissue resulting from prolonged pressure on the skin), a scar over bony prominence, or a non-removable dressing/device. [...]

Inspectors wroteBased on clinical record review, and interviews with staff, it was determined that the facility failed to follow physician order as ordered by the physician for one of three residents reviewed (Resident R1). Findings Include: Review of clinical record for Resident R1 revealed that the resident was admitted to the facility with diagnosis including Heart Failure and Chronic Kidney Disease. Review of physician order for Resident R1 dated October 11, 2023, revealed an order for daily weight and to notify the physician with weight gain of 2 pounds in one day or 5 pounds in 3 days. [...]

Inspectors wroteBased on the review of clinical records, staff interviews, it was determined that the facility failed to ensure that a physician's wound care recommendations to promote the healing of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) were followed as ordered and failed to ensure that the pressure ulcer prevention interventions were consistently implemented for one of three residents reviewed (Resident R1).