Dellridge Health & Rehabilitation Center

Based on interviews and review of other facility documentation, the facility failed to ensure that the physician must include an evaluation of the resident's condition and total program of care and a decision about the continued appropriateness of the resident's current medical regimen. The primary physician's history and physical and succeeding visit notes did not reflect resident's skin impairment and pressure ulcer. This deficient practice was identified for 1 of 27 residents, (Resident #14), reviewed for physician services.This deficient practice was evidenced by the following: On 4/17/26 at 8:34 AM, the surveyor reviewed the medical records of Resident #14, and revealed the following: The admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included but were not limited to; pressure ulcer (PU) of sacral region, stage 4 (a severe, full-thickness wound involving extensive destruction, tissue necrosis, and damage to muscle, bone, or supporting structures), muscle weakness (generalized), difficulty in…

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 facility documents, it was determined that the facility failed to a.) ensure the consultant pharmacist identified and reported irregularities in the medication regimen, b.) ensure duplicate and conflicting physician orders were clarified, and c.) ensure that as needed and routine orders were not duplicative or clinically appropriate. This deficient practice was identified for 1 of 27 residents (Resident #6) reviewed for orders.The deficient practice was evidenced by the following: On 4/16/26 at 10:10 AM, the surveyor observed Resident #6 in the resident's room lying in bed. The resident was alert and oriented, with the call bell within reach. The surveyor reviewed the medical record for Resident #6. A review of the admission Record or face sheet (an admission summary), revealed diagnoses which included, but were not limited to; multiple sclerosis, sepsis, extended spectrum beta-lactamase resistance, acute kidney failure, and depression. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCYBased on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to; a.) follow appropriate hand hygiene, use of personal protective equipment (PPE), and disinfect equipment for 1 of 4 nurses during medication pass observation, b.) perform hand hygiene and follow enhanced barrier precautions (EBP) for 1 of 1 staff (Housekeeper), and c.) track the extent to which staff were following the facility's policy and procedures to control infections and communicable diseases for all residents with regard to vaccinations, failed to follow appropriate infection control practices to prevent the spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24, revealed, EBP…

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 pertinent facility documents, it was determined that the facility failed to ensure all residents and/or resident representatives must be educated on the COVID-19 vaccine the facility offered, in a manner they could understand for 2 of 5 residents reviewed for immunizations (Residents #6 and #7). This deficient practice was evidenced by the following: 1.On 4/16/26 at 10:46 AM, Surveyor #1 (S #1) reviewed the medical record for Resident #6. A review of the admission Record (AR) or face sheet (an admission summary) for Resident #6, revealed diagnoses which included, but were not limited to; multiple sclerosis, sepsis, extended spectrum beta-lactamase resistance, acute kidney failure, and depression. A review of the comprehensive Minimum Data Set (MDS) (an assessment tool used to facilitate the management of care), with an assessment reference date (ARD) of 3/13/26, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of the immunization record for…

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 documents it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/15/24 at 9:28 AM, the surveyor, in the presence of the Food Service Director (FSD) and Regional FSD (RFSD), observed the following during the kitchen tour: 1. In the juice dispenser area, there were three 5-gallon beverage boxes that were past their best used by date. A thickened water (nectar consistency) 5-gallon box had a best if used by date of 9/11/24. A thickened water (honey consistency) 5-gallon box had a best if used by date of 7/31/24. A diet lemonade 5-gallon box had a best if used by date of 10/3/23. The FSD stated that the beverage boxes were good for 6 months after their best if used by date. The FSD acknowledged the diet lemonade was expired. The surveyor requested documentation from the RFSD and FSD which indicated the beverage boxes were still good to be used 6 months after the best if used by date. 2.…

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 provided documentation, the facility failed to adhere to professional standards of clinical practice by failing to: a.) follow the residents' meal tickets for 2 of 2 meal observations for Residents #41, #43, and #44; b.) clarify the physician's order with regard to supplement for 1 of 24 residents, Resident #41; and c.) ensure medication was administered in accordance with the manufacturer's specifications, and d.) ensure proper disposal of excess medication in a safe and approved manner for 2 of 6 residents, Residents #45 and #339, reviewed during the medication pass observation. 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 case-finding, health…

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 REPEAT DEFICIENCY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 5 of 11 staff (1 Housekeeper,1 Recreation Aide, 2 Dietary Staff, and 1 Physician), b.) disinfect the examination area after use, and follow appropriate infection control practices during meal observation, environment tour, and kitchen tour, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before…

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, and review of facility-provided documents, it was determined that the facility failed to ensure that a) meals were consistently provided in a dignified and homelike manner and b) resident meal assistance was provided in a dignified manner. The deficient practice was observed in the recreation dining room for 2 of 6 residents (Residents #15 & #44). The deficient practice was evidenced by the following: On 12/15/24 at 11:46 AM, the surveyor observed the Kitchen Staff (KS) deliver the food truck to the recreation room, there were 6 residents, 4 residents at one table, 1 resident at one table, and another resident at one table, there were 2 Recreation Aides (RA) inside the dining area and later Registered Nurse Supervisor (RNS) came and assisted in distributing lunch trays. The surveyor observed RA #1, RA#2, and RNS assisted 5 of 6 residents with hand hygiene using individually wrapped hand wipes on each resident's lunch trays. The facility staff did not offer Resident #44 hand…

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 facility documentation, it was determined the facility failed to ensure accurate documentation of a resident's advance directives for 1 of 7 residents (Resident #10) reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (electronic and paper) medical records of Resident #10 which revealed: The admission Record (a summary of important information about the resident) revealed that the resident was admitted with diagnoses that included but were not limited to, chronic respiratory failure (a chronic condition when the airways in the lungs become damaged and narrow), anxiety disorder, and type 2 diabetes mellitus. A Significant Change Minimum Data Set (MDS) assessment tool used to facilitate the management of care, dated 11/30/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #10 scored a 14 out of 15, which indicated the resident had no cognitive impairment. The New Jersey Practitioner Orders for…

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.

COMPLAINT NJ#169518 Based on interviews, review of medical records, and pertinent facility documentation, it was determined that the facility failed to notify the Resident's Representative (RR) of a change in condition for 1 of 24 sampled residents (Resident # 239). This deficient practice was evidenced by the following: The surveyor reviewed Resident #239's closed hybrid (paper and electronic) medical record. Resident #239's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dysphagia (difficulty swallowing foods or liquids), dementia (group of brain disorders that cause a gradual decline in cognitive abilities, such as memory, thinking, reasoning, and judgment) and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident #239's Universal Transfer Form (UTF) from the return to the facility after the first rehospitalization, indicated that the resident did not have any wounds.…

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, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding. This deficient practice was identified for 3 of 21 residents reviewed, Resident #48, #71 and #47. The deficient practice was evidenced by the following: 1. During the initial tour of the facility on 12/15/24 at 11:35 AM, the surveyor observed room [ROOM NUMBER]-LW and Resident #48 was not in the room. The surveyor observed dressers on both sides of the bed. Some areas of the wood on the left dresser and the edges of the right dresser were peeled, exposing the underlying particle board which created a rough surface and edges on the dressers. The heater unit in room [ROOM NUMBER]-LW was observed without the front grill cover. The front grill cover was observed laying against the wall. The surveyor also observed Resident #48's bed frame visibly soiled with a dry, brown substance on the right, foot side of the bed frame. On 12/15/24…

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 provide the necessary service to maintain good personal grooming for a resident who was unable to carry out activities of daily living (ADL). This deficient practice was identified for 1 of 21 residents reviewed for care, Resident #71. The deficient practice was evidenced by the following: On 12/15/24 at 11:12 AM, the surveyor observed Resident #71 lying on an air mattress inside their room. The resident waved to the surveyor but was unable to answer questions at that time. The surveyor observed Resident #71 unshaven, with hair stubbles on both cheeks, and beard on chin. On 12/16/24 at 11:28 AM, the surveyor observed the Resident #71 sitting on the wheelchair (w/c) inside their room, unshaven, and Certified Nursing Assistant #1 (CNA#1) was combing the resident's hair. The resident communicated to the surveyor and whispered their name when the surveyor asked for the name of the resident. On 12/16/24 at 11:39 AM, the surveyor interviewed CNA #1, who stated, I wash them, answer call bells,…

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.

REPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and facility policies and procedures for 1 of 24 residents, Resident #86, reviewed for quality of care. 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 case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act…

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 the facility's policy and procedure, specifically, administer oxygen therapy according to the physician's order by documenting the date and time the oxygen tubing was changed for 1 of 1 resident, Resident #10. 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 case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise…

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 documents, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice for 1 of 1 resident (Resident #25), reviewed for dialysis services. The 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 case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: 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 review of pertinent facility documents, it was determined that the facility failed to ensure that the 24-hour staffing report posted was accurate and in a prominent place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 12/15/24 at 8:56 AM, the survey team entered the facility. The surveyor did not observe a 24-hour staffing report in the initial hallway leading to the nursing station or at the nursing station. The surveyor then turned right and proceeded down a different hallway, which contained the lower odd numbered resident rooms and observed a staffing report sheet that was posted on the right wall next to the menu. The surveyor observed that the posting would not be accessible or visible to residents and visitors that were located or visited the resident rooms that were in the hallway that contained the higher odd numbered rooms. The posting observed was dated 12/13/24 evening shift with a census of 85. The posting had not been updated for that day and did…

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.

Complaint NJ#169518 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for 1 of 24 residents reviewed (Resident #239). This deficient practice was evidenced by the following: On 12/18/24 at 9:01 AM, the surveyor reviewed Resident #239's closed hybrid (paper and electronic) medical record. A review of Resident #239's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dysphagia (difficulty swallowing foods or liquids), dementia (group of brain disorders that cause a gradual decline in cognitive abilities, such as memory, thinking, reasoning, and judgment) and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident #239's Universal Transfer Form (UTF) from the return to the facility after…

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 #NJ00154277 Based on the interview, review of the facility closed record, and the review of facility provided documents, it was determined that the facility failed to: a) document the skin impairment of the resident, b) provide scheduled showers, c) administer medications according to the order of the physician, and d) notify the physician of late administration of prescribed medications in accordance with the resident's preferences, goals for care and professional standards of clinical practice for one (1) of 19 residents, (Resident#127) reviewed for quality of care and 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 case-finding, health teaching, health counseling, and provision 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility provided documents, it was determined that the facility failed to ensure a) proper storage of medication (med) for one (1) of 19 residents, Resident #32 observed during the first day of tour; b) med was available for one (1) of four (4) residents, Resident#45 during med administration observation; c) proper disposal of med for one (1) of three (3) nurses observed during med administration; d) med was administered according to the order of the physician for one (1) of 19 residents, Resident#129 observed during med cart inspection according to the standards of clinical practice and facility policies. 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…

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 pertinent facility documents, it was determined that the facility failed to thoroughly investigate a fracture of unknown origin on 3/02/23 of Resident#10. This deficient practice was identified for one (1) of three (3) residents reviewed for incident/accident and was evidenced by the following: On 7/06/23 at 10:59 AM, the surveyor observed Resident #10 seated in a wheelchair inside their room, with one floor mat to the left side of the bed. The resident stated to the surveyor that he/she had a fall incident last night while in the bathroom. At the same time, Certified Nursing Aide#1 (CNA#1) who was also inside the room informed the surveyor that she was the aide of the resident. The CNA stated that the fall incident happened not on her shift. On 7/11/23 at 9:09 AM, the surveyor observed the resident was not in their room, there was one floormat on the floor to the left side of the bed. On 7/11/23 at 9:10 AM, Licensed Practical Nurse#1 (LPN#1) informed the surveyor that Resident #10 was in the hospital, transferred to ER…

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 facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for Resident #10. This deficient practice was identified for one (1) of 19 residents reviewed, and was evidenced by the following: According to the MDS (minimum data set) 3.0 RAI (Resident Assessment Instrument) Manual October 2019 page 2-22 (pages 44-49) included that the SCSA is a comprehensive assessment for a resident must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care…

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 pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 3 (three) of 19 residents, (Residents #10, #11 and #54) reviewed, and was evidenced by the following: 1. On 7/06/23 at 10:59 AM, the surveyor observed Resident #10 seated in a wheelchair inside their room with the Certified Nursing Aide (CNA) with one floor mat to the left side of the bed and informed the surveyor that she was the aide of the resident. The resident stated to the surveyor that he/she had a fall incident last night while in the bathroom. The CNA stated that the fall incident happened not on her shift. On 7/11/23 at 9:09 AM, the surveyor observed the resident was not in their room, there was one floormat on the floor to the left side of the bed. On 7/11/23 at 9:10 AM, the Licensed Practical Nurse (LPN) came and informed the surveyor that Resident #10 was in the hospital, transferred to ER (emergency room) on 7/06/23 s/p…

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 facility provided documents, it was determined that the facility failed to follow and revised the diet slip of one (1) of 19 residents, Resident #32 observed during breakfast observation according to the standards of clinical practice. 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 case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 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…

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 documentation, it was determined that the facility failed to assess for risk for pressure ulcer quarterly and accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for one (1) of three (3) residents reviewed for pressure ulcer/injury (Resident #40). The deficient practice was evidenced by the following: On 7/06/23 at 10:48 AM, the surveyor observed Resident #40 lying in bed with an air mattress. The surveyor reviewed the medical records of Resident #40 which revealed the following: The admission Record (or face sheet; an admission summary) showed that the resident was admitted to the facility with medical diagnoses that included but were not limited to dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), anemia (condition marked by a deficiency of red blood cells or 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility provided documents, it was determined that the facility failed to: a) label and properly store the nebulizer (neb) mask for one (1) of two (2) residents, (Resident#126) reviewed for respiratory care and b) perform hand hygiene appropriately for one (1) (Licensed Practical Nurse) of three (3) staff observed during medication (med) administration in accordance with the Centers for Disease Control and Prevention (CDC) guidelines and facility policy. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 01/08/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids…

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.