River Edge Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at River Edge Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 8, 2026

  Based on clinical record review, interview, and facility documentation review, the facility failed to protect two of three residents (Resident (R) 109 and R81) reviewed for abuse from being sexually abused by R15 when the facility allowed the resident to sexually abuse vulnerable residents by not supervising R15, who had a known history of sexual inappropriateness out of 29 sample residents. This had the potential to affect all residents in the facility who were at risk for abuse. The facility's Administrator was informed on 05/07/26 at 1:33 PM that Immediate Jeopardy existed which also constituted Substandard Quality of Care (SQC) related to the facility's failure to ensure R109 and R81 were free from sexual abuse by R15 and was determined to exist on 03/15/25. […]

• Immediate jeopardy, isolatedF607May 8, 2026

  Based on clinical record review, interview, and facility documentation review, the facility failed to implement its abuse prevention and investigation policies to ensure the safety of two of three residents (Resident (R) 109 and R81) reviewed for abuse out of 29 sample residents. This had the potential to affect all residents in the facility who were at risk for abuse. The facility's Administrator was informed on 05/07/26 at 1:33 PM that Immediate Jeopardy existed which also constituted Substandard Quality of Care (SQC) related to the facility's failure to ensure R109 and R81 were free from sexual abuse by R15 and was determined to exist on 03/15/25. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 05/07/26 at 5:42 PM. […]

• Actual harm, isolatedF697Nov 3, 2022

  Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure pain management for one of 21 residents in the survey sample, Resident #78. Resident #78 was not administered scheduled pain medication as ordered by the physician; Resident #78 suffered unrelieved pain and was unable to sleep, which resulted in actual harm to the resident. Findings include: Resident #78's diagnoses included, but were not limited: diverticulitis, atrial fibrillation, depression, muscle weakness, dysphagia, abnormal gait, polyneuropathy, history of falls, and musculoskeletal mastoid bone pain. Resident #78's most recent MDS (minimum data set - CMS assessment tool) was an admission assessment dated [DATE]. […]

• No harm, potential for more than minimal, patternF550Aug 7, 2025

  Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain the dignity of multiple residents on one of two units during meal distribution. The findings included:The facility staff failed to serve all residents at the table at the same time. The facility staff failed to knock prior to entering resident rooms. The facility staff failed to provide adequate supervision during meals and failed to sit next to residents while assisting with meals. On 8/5/25 at 12:07 p.m., observations were conducted of the lunch meal service on the A-wing. At 12:07 p.m., the first cart of meal trays had just arrived on the unit and Resident #18 (R18) was observed sitting in the tv room with six other residents. R18 was served her meal. […]

• No harm, potential for more than minimal, patternF657Aug 7, 2025

  Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive plan of care for four of forty-one residents in the survey sample (Residents #2, #13, #20 and #24).The findings include:1. Resident #2's plan of care was not revised to include the resident's do not resuscitate status, enrollment in hospice services, or that a fall occurred on 7/4/25. Resident #2 (R2) was admitted to the facility with diagnoses that included dementia, psychotic disturbance, mood disorder, anxiety, chronic kidney disease, gastroesophageal reflux disease, obesity, congestive heart failure, peripheral vascular disease and cognitive communication deficit. […]