Riverview Estates Rehab and Senior Living Center

Inspectors wroteBased on observations, interviews, and review of facility provided documents it was determined that the facility failed to develop, follow, or change planned menus with review by a registered dietician (RD). This deficient practice was evidenced by the following:On 1/2/26 at 11:30 AM, during an initial tour of the facility, the surveyor was unable to locate a posted daily or weekly menu on 3 of 3 long-term care units toured. On 1/5/26 at 12:50 PM, the surveyor interviewed the Food Service Director (FSD) who stated the corporate office created the menus on a 3-week cycle and emailed them to her. She stated the facility was currently on Week 3. The FSD stated the corporate menus were also emailed to the RD, who entered the menus into [food service computer program name redacted] once a week, signed the menus and emailed them back to the FSD. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss mattress was functioning properly and accurately setup according to the resident's weight in accordance with a physician's order for a resident who was previously identified to have had an alteration in skin integrity. This deficient practice was identified for 1 of 2 residents (Resident #54) reviewed for pressure ulcers and was evidenced by the following:On 1/2/26 at 10:54 AM and 12:01 PM, the surveyor observed Resident #54 lying in bed, awake, on an air mattress. The resident's air mattress pump was observed to be set to a resident weight of 600 pounds. On 1/5/26 at 1:30 PM, the surveyor observed Resident #54 lying in bed, awake, watching TV, the air mattress pump was noted to be set to a resident weight of 600 pounds. [...]

Inspectors wroteBased on observations, interviews, record review and review of facility provided documents it was determined that the facility failed to document and implement resident preferences for one (1) of three (3) residents (Resident #9) reviewed for meal service. This deficient practice was evidenced by the following: On 1/2/26 at 11:05 AM, during the initial tour, the surveyor observed resident #9, a long-term care resident, in their bed, awake and watching television. Resident #9 stated they spoke to the dietician about their preference of grilled cheese and salads for lunch and dinner, but they do not always receive it. On 1/2/26 at 12:35 PM, the surveyor interviewed Resident #9, who stated they received a cheese quesadilla for lunch but had requested a grilled cheese sandwich. The cheese quesadilla on the resident's plate was observed by the surveyor at this time. [...]

Inspectors wroteRefer to F 803 and F 803Based on interviews and review of other facility documentation, it was determined that the facility Quality Assessment and Performance Improvement (QAPI) committee, that identified quality concerns, failed to utilize the Facility Performance Improvement Plan (PIP) to follow the facility process to measure and utilize data acquired for resident's food preferences. This deficient practice was evidenced by the following:The surveyor reviewed the facility provided, Performance Improvement Plan dated 5/20/2025, revised 10/2025 (and 1/6/2025-after surveyor inquiry) which revealed a Problem Statement: Food preference and meal ticket accuracy. Goal: Alert residents will be able to choose what meal or alternate they wish to have. Meal tickets reflect choice and what is printed. Further review revealed, Tasks: [...]

Inspectors wroteBased on interview and review of Nurse Staffing Report sheets, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 2 of 7 weekends reviewed. This deficient practice was evidenced by the following: 09/05/24 12:55 PM A review of the Facility Assessment with last reviewed date of 8/7/2024 revealed under the Staffing Plan the following: Day RN blank (no numerical indicator) LPN 2 CNA 1 to 8 residents Evening RN 0-1 LPN 2 CNA 1-10 residents Night RN 0-1 LPN 2 CNA 3 (no ratio provided) A review of the Nurse Staffing Report for the week of 12/3/2023 through 12/9/2023 revealed that on Satuday 12/9/2023 had all zeros for Day, Evening, and Night shift under RN column. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to respond to the consultant pharmacist (CP) medication regimen review recommendations (MRR) in a timely manner. This deficient practice was identified for 2 out of 5 residents (Resident #5 and Resident #50) reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. On 09/04/2024 at 09:33 AM, the surveyor observed Resident #5 in their room during the initial tour of the facility Resident #5 was polite and cooperative and did not display any aberrant behaviors. According to the admission Record, Resident #5 was admitted to the facility with the following but not limited to diagnoses: [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 9/4/2024 from 8:14 to 9:04 AM, the surveyors, accompanied by the Food Service Director (FSD) observed the following in the kitchen: 1. On an upper shelf in the dry storage room, a can of Pizza Sauce with Basil had a dent on the upper seam of the can. The FSD stated to the surveyors that it will be moved to designated dented can area. 2. A quarter pan in the walk-in freezer was placed on top of cardboard boxes. The quarter pan contained frozen puree moldings for lunch, according to the FSD. The pan was covered with plastic wrap. [...]

Inspectors wroteBased on interviews, medical record review, and review of other pertinent facility documentation, it was determined that the facility failed to follow professional standards of practice for documenting wound care on the Electronic Treatment Administration Record (TAR). This deficient practice was identified for 1 of 1 resident reviewed for wound care (Resident #15). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to A.) follow a physician order for PRN (as needed) oxygen use for 1 of 2 residents reviewed for Respiratory Care and B.) failed to implement infection control measures for the handling and storage of respiratory equipment for 2 of 2 residents reviewed for Respiratory Care, (Resident #18 and Resident # 5). This deficient practice was evidenced by the following: A. During the initial tour of the unit on 09/03/2024 at 06:55 PM, Surveyor #1 observed nebulizer mask dated 8/29 sitting on top of the nebulizer machine uncovered and exposed in Resident #18's room. A review of Resident #18' Electronic Medical Record (EMR) on 09/04/2024 at 11:07 AM revealed the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly label, store, and date medication in accordance with manufacturer recommendations. This deficient practice was observed in 1 of 2 medication carts (B/C cart) inspected during the medication storage and labeling task and was evidenced by the following: On 9/6/24 at 10:59 AM, in the presence of Licensed Practical Nurse (LPN #2), the surveyor inspected cart B/C. In the third drawer on the left side of the cart the surveyor observed a brown sticky substance stuck to the bottom of the drawer. In addition, while inspecting the remainder of the cart the surveyor found seven and a half loose tablets. Lastly upon controlled substance reconciliation the surveyor located a lorazepam liquid being stored on the medication cart. [...]

Inspectors wroteBased on observation, interviews, review of the medical record and review of other facility documentation, it was determined that the facility failed to: a.) ensure appropriate infection control practices were maintained during wound care; and b.) implement enhanced barrier precautions (EBP) for a resident with open wounds. This deficient practice was identified for 1 of 1 resident (Resident #15) reviewed for wound care and was evidenced by the following: 1. During the initial tour on 09/03/2024 at 6:42 PM, the surveyor observed Resident #15 lying in bed, which had a pressure relieving device attached to the end of the bed. Resident #15 was unable to be interviewed regarding wounds and wound care. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide a safe physical environment to prevent the likelihood of serious injury, harm, or death, by failing to: a.) ensure that two (2) janitor closets containing hazardous materials were securely locked and free from the likelihood of resident access, b.) ensure that two (2) treatment supply rooms which contained caustic, hazardous supplies and chemicals were locked and free from the likelihood of residents access, and c.) follow their facility's Storage of Chemicals Policy and Procedure. The 2 of 2 janitor closets and 2 of 2 treatment supply rooms throughout the facility, were observed to be in unsafe conditions and contained items that would be detrimental to the health and safety of the residents. [...]

Inspectors wroteBased on observation, interviews, and review of facility documentation it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination, and c.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 10/19/23 at 09:59 AM, in the presence of the cook, two surveyors toured the kitchen and observed the following: 1. In a metal knife station on a food prep area, there was one white handled knife with a serrated blade with greasy marks on the blade and green debris on the handle. There was one red handled knife with a serrated blade with liquid on the blade. [...]

Inspectors wroteComplaint NJ #: 162553; 164144 Based on interview, record review, and review of facility documents, it was determined that the facility failed to develop a person-centered comprehensive care plan to include the resident's: a.) fall risk, b.) bowel and bladder incontinence, c.) positioning during tube feedings, d.) dysphagia (difficulty swallowing), e.) potential for skin impairment, f.) actual skin impairment, and g.) change in condition in a timely manner for 1 of 17 resident (Resident #13) care plans reviewed. This deficient practice was evidenced by the following: 1. [...]

Inspectors wroteComplaint NJ #: 162553; 1164144 Based on interview, record review, and review of facility documents, it was determined that the facility failed to address recommendations from the wound care consultant in a timely manner for 1 of 1 resident (Resident #13) reviewed for pressure ulcers. This deficient practice was evidenced by the following: According to the admission Record, Resident #13 had diagnoses which included, but were not limited to, osteomyelitis (bone infection) of left ankle and foot, hemiplegia and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side, dementia, and altered mental status. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 04/15/23, included the resident's cognition was severely impaired. [...]

Inspectors wroteComplaint NJ#: 168234 Based on observation, interview, review of medical records and review of pertinent facility documentation, it was determined that the facility staff failed to a.) provide a safe environment to prevent the potential spread of infection by not implementing transmission-based precautions (TBP) used for persons suspected of having infections, diseases, or germs that are spread by touching the patient or items in the room, for a resident that had a contagious urinary tract infection (UTI), (Resident #6) 1 of 1 resident reviewed for TBP and b.) perform hand hygiene while assisting residents in the dining room for 1 of 1 dining rooms. This deficient practice was evidenced by the following: 1.) On 10/19/23 at 10:10 AM during tour, Resident #6 was observed sitting in the chair in her room getting equipment out of a bag to brush his/her hair. [...]

Inspectors wroteComplaint NJ #: 162553 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to notify the resident's representative of a change in condition for 2 of 17 residents, (Resident #6 and Resident #13) reviewed. This deficient practice was evidenced by the following: 1. According to the admission Record, Resident #6 was admitted to the facility with the diagnoses which included, but not limited to unspecified dementia and chronic kidney disease. The annual Minimum Data Set (MDS), an assessment tool that facilitates a resident's care, dated 08/29/23, indicated that Resident #6 was cognitively intact and required limited to extensive assistance with activities of daily living. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an incident/accident for 1 of 5 residents (Resident #306) reviewed for accident/incidents. This deficient practice was evidenced by the following: According to the admission Record, Resident #306 was admitted with diagnoses that included, but were not limited to, hypertension (high blood pressure), weakness, other abnormalities of gait (walking) and mobility, cognitive communication deficit, and dementia. A review of the Care Plan, initiated 10/26/2022, included the resident was a high risk for fall hx [history] of actual falls. A review of the facility provided investigations showed incomplete investigations and missing witness statements for the following dates: [...]

Inspectors wroteComplaint NJ #: 162553 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) consistenly document the completion of a wound treatment in accordance with a physician's order for 1 of 1 resident, (Resident #13) reviewed for pressure ulcer, b.) consistently document the positioning of a resident during and after tube feedings in accordance with a physician's order for 1 of 1 resident, (Resident #13) reviewed for tube feeding, c.) consistently document the application of heel booties in accordance with a physician's order for 1 of 1 resident, (Resident #13) reviewed for pressure ulcer, d.) obtain a physician's order to discharge the resident from the facility in accordance with professional standards of nursing practice for 2 of 2 residents reviewed for discharge, (Residents #12 and #22) and, e.) [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to consistently conduct neurological evaluations (neuro checks) after an unwitnessed resident fall for two (2) of 2 residents, (Resident #5 and #306) reviewed for falls. This deficient practice was evidenced by the following: 1.) According to the admission Record, Resident #306 was admitted with diagnoses that included, but were not limited to, hypertension (high blood pressure), weakness, other abnormalities of gait (walking) and mobility, cognitive communication deficit and dementia. A review of the Care Plan, initiated 10/26/2022, included the resident was a high risk for fall hx [history] of actual falls. Review of the Incident Reports indicated the following: -An unwitnessed fall on 01/12/23: [...]

Inspectors wroteBased on record review and interview it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents reviewed a resident's urinanalysis and culture and sensitivity (UA and C&S) and prescribed the correct medication to treat an infection for 1 of 13 residents reviewed (Resident #6) and was evidenced by the following: According to the admission Record, Resident #6 was admitted to the facility with the diagnoses which included, but were not limited to, unspecified dementia and chronic kidney disease. The annual Minimum Data Set (MDS), an assessment tool that facilitates a resident's care, dated 08/29/23, indicated that Resident #6 was cognitively intact and required limited to extensive assistance with activities of daily living. [...]