Bergen New Bridge Medical Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # 2665060 Based on interviews, medical record review, and review of pertinent facility documentation, it was determined on 11/18/25, that the facility failed to ensure the Certified Nursing Assistant (CNA) flow sheets were complete and accurate. this deficient practice was identified for 2 of 3 residents reviewed for resident accuracy (Resident #1, and Resident #2).The findings were as followed: 1.A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to; pneumonia and urinary tract infection. A review of Resident #1's comprehensive Minimum Data Set (MDS), an assessment tool dated 10/28/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 of 15, indicating that the resident's cognition was severely impaired. A review of Resident #1's care plan with an original date of 5/5/25 revealed that the resident needed assistance with self care and mobility due to non-ambulatory status and…

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 policy review, it was determined that the facility failed to; a) sanitize and air-dry steam table pans correctly to prevent microbial growth, b) follow labeling requirements on food products and use-by dates, and c) maintain food and supply storage. This deficient practice was evidenced by the following: On 5/8/25 at 9:45 AM, in the presence of the Operations Managers (OM #1 and # 2) and Executive Administrator (EA), the surveyor observed the following: 1. In the dishwashing area, the surveyor observed 42 steam table pans wet nested as they were stacked with pooling water between them. The surveyor interviewed the Food Service Worker (FSW), who stated, In the morning we stack the pans. The FSW could not explain why there was water between the pans. At this time, the surveyor also interviewed the OM # 1 and # 2, who stated The pans need to be air dried. 2. At 9:55 AM, in the dish washing area, the surveyor observed the three-compartment sink and the Food Service Director (FSD) used a test strip to check the chemical 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ # 169798 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that the devices used to identify call bell notifications were functioning properly. This deficient practice had the potential to affect all residents residing in Unit 8-7. This deficient practice was evidenced by the following: On 5/12/25 at 1:33 PM, the surveyor upon exit from the elevator, the surveyor observed unit 8-7's call light system machine in the nursing station had a red button on with no audible sounds. There were five staff in the nursing station including the Registered Nurse/Unit Manager (RN/UM). Afterward, the surveyor went to left wing side of Unit 8-7. While the surveyor in the hallway, the surveyor heard one resident yelling for a nurse in Resident room [ROOM NUMBER] (RR#709). The light on top of the door for RR#709 was on with no audible sounds. There was no staff responded to RR#709's call light. On 5/12/25 at 1:40 PM, the surveyor…

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, it was determined that the facility failed to inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives to a resident receiving antipsychotic medications. This deficient practice was identified for 1 of 5 residents (Resident #213), reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 5/8/25 at 10:35 AM, the surveyor observed Resident #213 walking in the hallway towards the activity room. On 5/12/25 at 10:00 AM, the surveyor observed the resident in the day/activity room sitting on a chair with other residents, non-verbal, and no behaviors observed. The surveyor reviewed the medical records of Resident #213, and revealed: A review of the face sheet (admission summary) reflected that the resident was admitted to the facility with diagnosis which included but was not limited to; Alzheimer's (progressive disease that affects memory, thinking and behavior), dementia (declining memory and thinking skills), major depressive disorder (MDD)…

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 review of pertinent facility documentation, it was determined that the facility failed to ensure 3 of 32 residents (Residents #20, #83, and #228) call bells were within reach and able to use to accommodate residents' needs. This deficient practice was evidenced by the following: 1. On 5/8/25 at 1:09 PM, Surveyor #1 (S#1) observed Resident #20 in their room and observed that the call bell was not visible. The resident stated that they did not know where the call bell was located. On 5/12/25 at 10:20 AM, Surveyor #2 (S#2) interviewed Certified Nursing Assistant #1 (CNA#1), who cared for Resident #20, who stated that the resident should have the call bell in reach for use. 2. On 5/8/25 at 12:20 PM, S#1 observed Resident #228 awake and alert in their bed. The surveyor observed that the call bell was not visible. The resident stated that they did not know anything about a call bell and that they would call out to the staff for help. On 5/12/25 at 10:48 AM, S#2 observed Resident #228 in bed, and observed the call bell hanging off the wall, behind 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 1 of 32 residents (Resident #132), and 1 unsampled resident (Resident room [ROOM NUMBER]). The deficient practice is evidenced by the following. 1. On 5/8/25 at 11:10 AM, the upon initial tour of the 6th floor, the surveyor observed that inside of Resident room [ROOM NUMBER] (RR#606), there was damage to residents' wall with paint chipped off in five areas, across from the residents' bed. The surveyor also observed damage to the cove base near the residents' closet. The surveyor also observed a 1 inch sized break in the floor tile, also near the resident's closet. 2. On 5/8/25 at 11:16 AM, the surveyor observed that inside Resident #132's room, there were 11 areas of chipped off paint on wall near bathroom. The surveyor also observed damage to the cove base near the resident's closet and damage to wall, exposing sheetrock near closet as well. Lastly,…

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 review of other pertinent facility documents, it was determined that the facility failed to ensure timely revision of the individualized comprehensive care plan and implementation of interventions created by the occupational therapist to stimulate functional performance and prevent further decline. This deficient practice was identified for 1 of 3 residents reviewed for limited range of motion, Resident #25 and was evidenced by the following: On 5/8/25 at 10:30 AM, the surveyor observed the Certified Nursing Assistant (CNA), walking into Resident #25's room, and stated she was there to provide morning care to the resident. On 5/8/25 at 10:36 AM, the surveyor observed the same CNA exited Resident #25 room. The surveyor observed the resident awake, alert, in bed, with closed fist on both hands. The surveyor reviewed the medical record for Resident #25. A review of Resident #25's face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included unspecified injury and skull fractures. A review of…

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 review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen, according to the standard of clinical practice and facility's policy and procedure, specifically a.) the sterile water bottle utilized for humidification of oxygen was dated for 1 of 8 residents reviewed for respiratory care (Resident #80), and b.) that respiratory equipment were stored in accordance with infection control measures for 1 of 8 residents reviewed for respiratory care (Resident #124). This deficient practice was evidenced by the following: 1. On 5/13/25 at 12:15 PM, the surveyor observed Resident #80 lying in bed with oxygen (O2) being administered at 2 LPM (liters per minute) via nasal cannula (NC) tubing. The surveyor observed that the O2 being administered was being humidified by an attached bottle of sterile water and the bottle was not dated. On 5/13/25 at 12:16 PM, the surveyor interviewed the Licensed Practical Nurse (LPN),…

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, it was determined that the facility failed ensure a high blood pressure medication with parameters (defined set of conditions) was administered without significant medication error, the physician's order was followed, adhered to the professional standards of practice and the facility policy of medication administration. The deficient practice was identified for 1 of 4 residents (Resident #81), administered by 1 of 4 nurses observed during the medication administration and was evidenced by the following: On 5/12/25 at 10:06 AM, the surveyor observed Licensed Practical Nurse (LPN) prepare 8 medications (meds) for Resident #81, which included a physician's order (PO) for metoprolol tartrate 25 milligrams (mg) 1 tablet (tab) orally three times a day at 8:00 AM, 2:00 PM (6 hours apart), and 10:00 PM for hypertension (high blood pressure). Hold if systolic blood pressure (bp) less than 110; hold if heart rate less than 55. To be taken with food or milk. Give medication (med) without regard to meals. At 10:29 AM, the LPN confirmed she 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.

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to obtain written consent for the administration of an influenza (flu) vaccine and pneumococcal vaccine for 1 of 5 residents, Resident #213, reviewed for immunizations. This deficient practice was evidenced by the following: On 5/8/25 at 10:35 AM, the surveyor observed Resident #213 walking in the hallway towards the activity room, appears well groomed. The surveyor reviewed the medical record for Resident #213. A review of the Resident's face sheet (admission summary) revealed diagnosis which included but was not limited to Alzheimer's (progressive disease that affects memory, thinking and behavior) and dementia (declining memory and thinking skills. A review of the quarterly Minimum Data Set (MDS), an assessment tool, revealed the resident as rarely understood. According to the Resident's immunization electronic record, the resident received the flu vaccine on 10/2/24, and the pneumococcal vaccine on 11/6/19, with no consents found in the medical record. On…

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 observation, interview, record review, and review of pertinent facility documents it was determined, the facility failed to a.) transcribe a Physician's Order (PO) for a resident's multivitamin from 1/30/23 through 3/29/23 for (Resident #330); b.) obtained a PO for a dietary supplement from 11/1/22 through 2/6/23 for (Resident #90). This was idenified for two (2) of thirty-six (36) residents reviewed for professional standards of practice; and c.) obtain a re-weight on 11/2/22, 12/5/22 and 1/19/23, after a significant change of weight for one (1) of seven (7) residents, (Resident #90) reviewed for nutrition. 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 registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as…

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 observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure safety measures were consistently followed for a resident who required a two- person transfer with a mechanical lift. This deficient practice occurred for 1 of 12 residents reviewed for accidents (Resident #5) and was evidenced by the following: On 03/29/23 at 10:27 AM, the surveyor conducted a tour of the Unit-8 Korean Unit and observed a Certified Nurse Aide (CNA) exit a resident room and enter another resident room across the hall where a Recreation Aide (RA) was visiting a resident. The CNA then stated to the RA, Can you stand by me? The surveyor observed both staff then enter the resident room across the hallway (Resident #5) and then closed the door. The RA exited the closed door at 10:30 AM (three minutes later) and the surveyor interviewed the RA at that time. The RA stated the CNA used the [mechanical lift] to transfer Resident #5 from the bed to a recliner chair. 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, and record review, it was determined that the facility failed to maintain resident care equipment and personal items clean and sanitary for 1 of 35 residents (Resident #30) reviewed for safe, clean, comfortable, and homelike environment. This deficient practice was evidenced by the following: On 3/23/21 at 10:45 AM during the initial tour of unit 11-2, the surveyor observed Resident #30 in the bed with eyes closed. There was a tube feeding (TF) pole and feeding pump at the bedside providing the resident with nutritional support. The surveyor observed the base of the TF pole had a heavily soiled coating of dried tan colored substance and the floor under the TF pump was soiled with the same dried substance observed at the base. The TF pump was soiled with dried tan colored substance droplets that were sticky to the touch, and there was also a dried light tan colored film on the entire surface of the TF pump. The over bed table was soiled with splatter of dried white and tan colored substance. There was a suction machine on the over bed table that 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.

Based on observation, interview, and review of facility documents it was determined that the facility failed to store a controlled substance in a manner that would decrease the possibility of loss or drug diversion. This deficient practice was found in 1 of 27 medication carts inspected (cart #2 on Unit 11-5) and was evidenced by the following: On 3/24/21 at 9:40 AM, the surveyor inspected medication cart #2 (1 of 2 medication carts) on Unit 11-5 in the presence of the Licensed Practical Nurse (LPN) assigned to that cart. Upon inspection of the top drawer of the cart the surveyor observed 1 Tramadol 50 mg pill (an opioid analgesic/controlled substance) in its unit dose packaging under a container that held an opened vial of insulin. The surveyor asked the LPN if she noticed the pill was there when she took possession of the medication cart that morning. She stated she did not notice it. The surveyor checked the compartment that held the controlled substances. The compartment was locked. The surveyor and the LPN counted the controlled substances in the compartment and compared them…

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.