Glen Ridge Health Campus

Based on observation, interview, record review, facility policy review, and review of manufacturer's information, the facility failed to ensure the medication error rate was less than 5 percent (%). The facility had 4 medication errors out of 26 total opportunities, affecting 2 of 3 residents reviewed during the medication administration task (Resident (R)54 and R58), which resulted in a medication (med) error rate of 15.38 %. The findings include: Review of the facility policy titled, Medication Administration - General Guidelines, revised 11/2018, revealed medications were to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Continued review of the policy revealed, the FIVE RIGHTS for medication administration revealed the rights included: right resident; right drug; right dose; right route; and right time and were to be applied for each medication being administered. Per policy review, The policy medications were to be administered in accordance with written orders of the prescriber. Further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of the Centers for Medicare and Medicaid (CMS) Long-Term Care Facility, Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) Assessment for 1 of 16 sampled residents (Resident (R)54). The findings include: Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, Version 1.19.1, dated 10/2024, revealed under section O0110: Special Treatments, Procedures, and Programs, O0110C1, Oxygen therapy specified, Code continuous or intermittent oxygen administered via [by way of] mask, cannula, etc. [et cetera], delivered to a resident to relieve hypoxia in this item. Review of the Resident Face Sheet for R54 revealed the facility admitted the resident on 04/21/2025, with diagnoses to include pulmonary embolism, acute respiratory failure with hypoxia, pulmonary fibrosis, pulmonary hypertension, and atelectasis (complete or partial collapse of a lung or a lobe of a lung). Review of the admission MDS Assessment, with an Assessment Reference Date (ARD) of 04/25/2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility standard operating procedure review, the facility failed to obtain orders for supplemental oxygen use for 1 of 1 resident reviewed for respiratory care, out of the 16 total sampled residents (Resident (R)54). The findings include: Review of the facility's standard operating procedure (SOP) titled, Administration of Oxygen, last reviewed 12/13/2024, revealed, OVERVIEW Guidelines to properly Administering Oxygen and any Respiratory procedure. SOP DETAILS 1. Verify physician's order for the procedure. Review of R54's Resident Face Sheet revealed the facility admitted him/her on 04/21/2025, with diagnoses to include: pulmonary embolism, acute embolism and thrombosis of unspecified deep veins of left lower extremity, acute respiratory failure with hypoxia, atelectasis (complete or partial collapse of a lung or a lobe of a lung), pulmonary fibrosis, and pulmonary hypertension. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/25/2025, revealed the facility assessed R54 to have a Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility document and policy review, the facility failed to protect a resident's right to be free from mental abuse perpetrated by a staff member for 1 of 2 sampled residents reviewed for abuse, out of the total sample of 16. The findings include: Review of the facility policy titled, Abuse and Neglect Procedural Guide, reviewed 08/29/2019, revealed the facility was to protect residents from abuse. Further review revealed Mental/Emotional Abuse was defined as the use of verbal or nonverbal conduct which caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Review of the Resident Face Sheet for Resident (R)214 revealed the facility admitted the resident on 03/11/2025, with diagnoses of emphysema, acute respiratory failure with hypoxia, acute kidney failure, and acute on chronic diastolic heart failure. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/17/2025, revealed the facility assessed R214 to have a Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility document and policy review, the facility failed to submit an initial report of an allegation of staff-to-resident abuse to the State Survey Agency (SSA) within two hours for 1 of 2 sampled residents reviewed for abuse (Resident (R)214). The findings include: Review of the facility policy titled, Abuse and Neglect Procedural Guide, reviewed 08/29/2019, revealed Mental/Emotional Abuse was defined as using verbal or nonverbal actions which caused or had the potential to cause a resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Review of the section of the policy titled, Identification, revealed the Executive Director (ED) was responsible for notification to the State Department of Health (per State guidelines) and other agencies, which include the Ombudsman, Adult Protective Services (APS) and/or local law enforcement agencies, as indicated. Continued review of the policy revealed under the section titled, Reporting/response, revealed the facility was to ensure all alleged violations involving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, it was determined, the facility failed to ensure personal privacy for one (1) of six (6) sampled residents reviewed for dignity (Resident #32). Observation revealed staff obtained Resident #32's blood glucose level and administered insulin in the resident's abdomen while he/she was seated at a table in a common area with five (5) other residents. The findings include: Review of the facility policy titled, Resident Rights Guidelines, revised 05/11/2017, revealed the purpose of the policy was To ensure resident rights are respected and provide an environment in which they can be exercised. Further policy review revealed facility residents had the right to be treated with dignity and respect and privacy. Review of Resident #32's Resident Face Sheet revealed the facility admitted the resident on 10/03/2022 with diagnoses which included type 2 diabetes. Review of Resident #32's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/23/2024, revealed the facility assessed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of facility documents and policy, it was determined the facility failed to ensure resolution of a grievance for one (1) of twenty (20) sampled residents, (Resident #9). Interview with staff revealed they were aware Resident #9 did not sleep well at night due to his/her roommate's yelling/screaming out, and reported everyone knew about that information. However, the facility failed to make prompt efforts to resolve the resident's complaint/grievance and ensure he/she received the care and treatment necessary to achieve adequate rest/sleep at night. The findings include: Review of the facility policy titled, Resident Concern Process, effective 11/13/2019, revealed, the purpose of the policy was To provide a process for handling, tracking and resolving customer concerns to provide excellence in customer service. Continued review revealed the facility was to provide an open and customer friendly atmosphere for residents and their families/representatives to voice concerns and problems to ensure their concerns were heard and acted upon. Per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, it was determined the facility failed to implement the bowel protocol in accordance with physician's orders for one (1) of one (1) sampled resident for bowel management (Resident #213) out of the total sample of twenty (20) residents. The facility failed to implement the bowel protocol for Resident #213, when the resident exceeded 72 hours with no bowel movement (BM). The findings include: Review of the facility policy titled, Bowel Protocol Guidelines, reviewed on 12/31/2023, revealed its purpose was to provide guidance for the use of bowel stimulants for residents with constipation. Per policy review, the procedures included upon admission, an order might be obtained to 'Utilize Bowel Protocol as needed for the newly admitted resident. Continued review revealed if the resident needed to utilize the bowel protocol, the 'Bowel Protocol' order set might be opened and orders entered from the order set for the affected resident. Review of the policy revealed the Ineffective Bowel Pattern Event should be initiated for any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide necessary foot care for one (1) of seven (7) residents sampled for activities of daily living (ADLs), (Resident #3). Observation revealed Resident #3's toenails extended half an inch to one (1) inch beyond the tips of his/her toes. The findings include: A policy was requested regarding nail care on 03/15/2024 at 4:45 PM; however, the Assistant [NAME] President of Clinical Operations stated the facility did not have a policy that addressed toenail care. Review of Resident #3's Resident Face Sheet revealed the facility admitted the resident on 03/25/2022, and most recently readmitted the resident on 12/24/2022, with diagnoses that included unspecified dementia, chronic respiratory failure with hypoxia (low oxygen level in the blood), chronic kidney disease with heart failure, and chronic obstructive pulmonary disease (COPD). Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/21/2023, revealed a Staff Assessment for Mental Status (SAMS) determined…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to assist one (1) of seven (7) residents sampled for review of activities of daily living (ADL) care, (Resident #3). Observation revealed Resident #3's feet were dry with a buildup of black, dry, and flaky skin between and under the toes. Additionally, the skin on the resident's heels was also observed as dry and flaky with a buildup of callused skin on the right heel. The findings include: Review of the facility policy titled, Guidelines for Pressure Prevention, last reviewed on 12/31/2023, revealed to moisturize residents' skin with lotion or cream (if applicable) to keep skin soft and pliable. Continued review of the policy revealed to pay special attention to bony prominences and Keep skin clean, dry and free of body wastes, perspiration, and wound drainage. Review of Resident #3's Resident Face Sheet revealed the facility originally admitted the resident on 12/24/2022, and most recently readmitted him/her on 03/25/2022, with diagnoses that included chronic kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to identify and implement appropriate safety interventions for one (1) of six (6) sampled residents (Resident #213) reviewed for accidents/hazards out of the total sample of twenty (20) residents. The facility failed to identify loose screws in a round metal ring that covered the grab bar in Resident #213's shower which contributed to the resident's fall on 02/09/2024. The findings include: The State Survey Agency (SSA) was not provided a policy related to the prevention of accidents and incidents. However, during an interview with the Executive Director, on 03/15/2024 at 1:50 PM, he stated it was his expectation that maintenance issues would be reported and repaired for the safety of the residents. Review of Resident #213's Resident Face Sheet revealed the facility admitted him/her on 01/04/2024, with diagnoses that included dementia and osteoarthritis. Review of Resident #213's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 01/05/2024, revealed the facility assessed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide pharmaceutical services to meet the needs of one (1) of six (6) sampled residents reviewed for pharmacy services (Resident #209). The facility admitted Resident #209 on 09/25/2023; however, failed to ensure the resident's medications were ordered from the pharmacy until the following day, on 09/26/2023. Consequently, Resident #209 missed ten (10) doses of his/her routine medications on 09/26/2023, because the medications were not available. The findings include: Review of a facility policy titled, Provider Pharmacy Requirements, revised in November 2018, revealed Regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies. Continued review of the policy revealed under the procedures area, section D the provider pharmacy agreed to perform the following pharmaceutical services provision of routine and timely pharmacy service as contracted, and emergency pharmacy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to ensure staff accurately coded the Minimum Data Set (MDS) assessment for one (1) of five (5) sampled residents, Resident #41, related to falls. Resident #41 sustained a fall prior to admission and had a fall in the facility; however, the falls were not identified on the MDS. The findings include: Interview with MDS Coordinator #1, on 04/26/19 at 3:37 PM, revealed the facility did not have a policy to ensure MDS assessments were accurately coded but the facility followed the RAI User's Manual to code assessments. Review of the CMS RAI 3.0 User's Manual, Version 1.16, dated October 2018, Chapter 3, pages J-27 through J-35, revealed the facility should code item J1700A, Fall History on Admission/Entry or Reentry, as 1-Yes if the resident or family report, or transfer records or medical records documented a fall in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection control program to help prevent the transmission of disease and infection for one (1) of fourteen (14) sampled residents, Resident #16. Observation revealed Licensed Practical Nurse (LPN) #3 and Certified Resident Care Associate (CRCA) #1 exited Resident #16's isolation room without washing their hands. In addition, the Activities Director walked into Resident #16's isolation room without donning Personal Protective Equipment (PPE) and left without washing her hands, and entered another resident's room. The findings include: Review of the facility's policy, Guidelines for Handwashing/Hand Hygiene, reviewed 02/19/17, revealed handwashing was the single most important factor in preventing transmission of infections. Health care workers were to perform hand hygiene before and after having direct physical contact with residents. Review of the facility's policy, Guidelines for Contact Precaution, reviewed 05/22/18, revealed the purpose was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.