Ridgewood Center

REPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to a.) ensure that the physician orders were followed and orders for blood work was transcribed and followed for 1 of 20 residents, (Resident #59), and b.) adhere to appropriate disposal of unused medication for 1 out of 3 residents, (Resident #65), observed during the medication pass, according to the standard of clinical practice and facility policy. 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…

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 #184234 Based on interview, observation, and record review, it was determined the facility failed to; a.) update a resident's discharge goals based on the resident's representative (RR) wishes, b.) hold an interdisciplinary care plan meeting to collaborate with the RR on an updated discharge planning process, c.) and document in the electronic medical record , for 1 of 2 residents, (Resident #9), reviewed for discharge planning. This deficient practice was evidenced by the following: On 4/7/25 at 9:25 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #9. A review of the admission Record (or face sheet, an admission summary) documented that the resident had diagnoses that included but were not limited to, dementia, and adult failure to thrive (a decline in overall health and well-being in older adults). A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 3/13/25, revealed a Brief Interview for Mental Status (BIMS) score of 99, which reflected the resident was unable to complete 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 review of other pertinent facility documentation, it was determined that the facility failed to, a.) maintain the necessary respiratory care and services of residents by following the physician orders and b.) verify the duplicate order for one 1 of 1 resident, (Resident #39), reviewed for respiratory care, in accordance with professional standards of practice and facility policy. 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. On 4/6/25 at 9:45 AM, 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 was accurately posted and in a prominent place within the facility readily accessible and visible to the residents and the visitors. This deficient practice was evidenced by the following: On 4/6/25 at 9:00 AM, the surveyor entered the facility. The surveyor observed that the Nursing Home Resident Care Staffing Report (NHRCSR) that was posted on the table across from the receptionist desk was dated 4/3/25, day shift. The NHRCSR was not up to date. On 4/8/25 at 12:31 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Clinical Lead of New Jersey(CLoNJ) the concern that the staffing report that was posted and observed on 4/6/25 was dated 4/3/25, and was not up to date. The LNHA stated that it should be posted every day. On 4/9/25 at 9:44 AM, the surveyor interviewed the Scheduling & Payroll Manager (SPM) regarding posting of the NHRCSR. The SPM stated that she would print…

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.

NJ#176708 Based on observation, interview, and review of facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate accountability of controlled substances, have sufficient secure procedures in place to prevent further diversion of controlled substances, and to educate all staff on accountability procedures for controlled substances. This deficient practice was identified for 1 of 2 years of controlled substances accountability reviewed. 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…

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 interviews, record review, and a review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify irregularity for 1 of 3 residents, (Resident #62), during the medication pass observation. This deficient practice was evidenced by the following: On 4/8/25 at 9:31 AM, the surveyor observed the Licensed Practical Nurse (LPN) assigned to the medication cart (med-cart) located on the East Wing Unit, High Side, prepare and administer due medications (meds) to Resident #62. The surveyor observed the LPN prepare and administer Linzess (a medication (med) used to treat irritable bowel syndrome with constipation). The med was scheduled to be given at 9:00 AM per the physician's orders (PO) and the LPN was within the accepted time based on the order. The surveyor observed on the Linzess med container labeling that reflected to take on an empty stomach. The surveyor asked the LPN about the labeling. The LPN stated they noticed it and was going to call the physician to ask about it. The surveyor concluded the med-pass. 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 and record review, it was determined that the facility failed to a.) assure that the required staff attended the quarterly Quality Assurance (QA) meetings for 2 of 4 quarterly QA meetings and b.) ensure there was a scheduled frequency of meetings and reporting according to the regulation and facility's policy. This deficient practice was evidenced by the following: On 4/8/25 at 3:09 PM, the surveyor reviewed the QAPI (Quality Assurance Performance Improvement) Plan, dated 1/1/25, and the Center Quality Assurance Performance Improvement Process Policy that was provided by Licensed Nursing Home Administrator #1 (LNHA#1) on 4/7/25 at 8:20 AM, and revealed that the facility QAPI members will meet at least quarterly. The LNHA also provided the QAPI sign in sheets and revealed: 7/24/24=10 attendees signed and did not include their titles. 8/22/24=nine attendees signed and did not include their titles. 9/25/24=12 attendees signed and did not include their titles. 10/29/24=11 attendees signed and did not include their titles. 11/26/24=11 attendees signed and did not…

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 offer a resident a pneumococcal vaccine. This deficient practice was identified for 1 of 5 residents, (Residents #57), reviewed for immunizations. This deficient practice was evidenced by the following: On 4/9/25 at 11:12 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #57 for immunizations. A review of the admission Record (or facesheet, an admission summary) documented that Resident #57 was recently admitted and had diagnoses that included but were not limited to; dementia, chronic atrial fibrillation (an irregular, rapid heart rate that commonly causes poor blood flow), and hypertension (high blood pressure). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 3/11/25, indicated a Brief Interview for Mental Status (BIMS) test was not completed as the resident was documented as being rarely/never understood. Section O of the MDS indicated the resident's pneumococcal vaccination was up to…

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 and record review, it was determined that the facility failed to offer a resident a coronavirus-19 (COVID-19) vaccine. This deficient practice was identified for 1 of 5 residents, (Residents #57), reviewed for immunizations. This deficient practice was evidenced by the following: On 4/9/25 at 11:12 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #57 for immunizations. A review of the admission Record (or facesheet, an admission summary) documented that Resident #57 was recently admitted and had diagnoses that included but were not limited to; dementia, chronic atrial fibrillation (an irregular, rapid heart rate that commonly causes poor blood flow), and hypertension (high blood pressure). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 3/11/25, indicated a Brief Interview for Mental Status (BIMS) test was not completed as the resident was documented as being rarely/never understood. Section O of the MDS did not indicate if the resident was up to date or not with…

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 and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that included effective communications for 3 of 5 Certified Nurse Aides (CNAs), reviewed for mandatory education (CNA #1, #4 and #5). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire. On 4/7/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist/Educator Licensed Practical Nurse (IP/E/LPN) regarding the education process. The IP/E/LPN stated that she started in February and that the education was done in person and in an electronic system. She added that all of the education was in the electronic system since the in person educations were entered into the electronic system. On 4/8/25 at 12:45 PM, the IP/E/LPN provided the Student and Group Transcript Report for the five CNAs with the date range of April 9, 2024 to April 8,…

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 and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that included rights of the resident and the responsibilities of a facility to properly care for its residents for 2 of 5 Certified Nurse Aides (CNAs), reviewed for mandatory education (CNA #4 and #5). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire (doh). On 4/7/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist/Educator Licensed Practical Nurse (IP/E/LPN) regarding the education process. The IP/E/LPN stated that she started in February and that the education was done in person and in an electronic system. She added that all of the education was in the electronic system since the in person educations were entered into the electronic system. On 4/8/25 at 12:45 PM, the IP/E/LPN provided the Student and Group Transcript…

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 and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for 3 of 5 Certified Nurse Aides (CNAs), reviewed for mandatory education (CNA #1, #4 and #5). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire (doh). On 4/7/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist/Educator Licensed Practical Nurse (IP/E/LPN) regarding the education process. The IP/E/LPN stated that she started in February and that the education was done in person and in an electronic system. She added that all of the education was in the electronic system since the in person educations were entered into the electronic system. On 4/8/25 at 12:45 PM, the IP/E/LPN provided…

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 and review of facility documentation, it was determined that the facility failed to ensure that a) Certified Nurses Aides (CNA) received 12 hours of mandatory annual in-service training for 1 of 5 CNAs reviewed (CNA #4); b) CNA education included resident abuse prevention training for 1 of 5 CNAs reviewed (CNA #4); and c) dementia management training for 2 of 5 CNAs reviewed (CNA #4 and CNA #5). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire (doh). On 4/7/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist/Educator Licensed Practical Nurse (IP/E/LPN) regarding the education process. The IP/E/LPN stated that she started in February and that the education was done in person and in an electronic system. She added that all of the education was in the electronic system since the in person educations were entered into the electronic system. On 4/8/25 at…

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, record review, and review of other facility documentation, it was determined the facility failed to ensure accurate documentation and review of a resident's advance directives for 3 of 18 residents (Resident #49, #36, #8) reviewed. This deficient practice was evidenced by the following: 1. On 11/28/23 at 11:51 AM, the surveyor observed Resident #49 sitting in a wheelchair in their room. The resident was alert, pleasant, and verbalized no concerns. A review of Resident #49's hybrid (electronic and paper) medical records revealed the following: According to the admission Record (an admission summary) the resident was admitted with diagnoses that included but were not limited to, Dementia, Anxiety Disorder, and Schizophrenia. A physician's order, dated 11/15/2021 read, DO NOT RESUSCITATE (DNR). A physician's order dated 11/15/2021 read, DO NOT INTUBATE (DNI). The resident's paper chart included: an Advance Directives acknowledgement form dated 11/3/21 and signed by the resident's representative, a completed 'PROXY DIRECTIVE- (Durable Power of Attorney…

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 #: NJ00162688, NJ00161423 Based on observation, interview, and record review, it was determined that the facility failed to maintain resident's equipment and living areas in a clean and home like manner. This deficient practice was identified for 2 of 20 residents (Resident #54 and Resident # 67) and was evidenced by the following: 1. On 11/28/23 at 11:40 AM, the surveyor observed Resident #54 in the day room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #54's hybrid medical records. The admission Record (AR) reflected that Resident #54 was admitted to the facility with medical diagnoses which included but not limited to Dementia, Hypertension, Type 2 Diabetes Mellitus and Hyperlipidemia. According to Resident #54's Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 10/27/23, the Brief Interview for Mental Status (BIMS) was not conducted due to resident's cognitive status which revealed that the resident had memory problem with both short-term and long- term…

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 #: NJ00162321 Based on observation, interview, and record review it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 4 of 20 residents reviewed, Resident #18, #69, #8, and #170. This deficient practice was evidenced by the following: 1. On 11/28/2023 at 11:59 AM, the surveyor observed Resident #18 in bed with eyes closed. The surveyor observed the resident with a wander guard (wander guard is an electronic device made for the purpose of keeping elderly people or people with dementia from wandering as well as alerting the caregiver whenever his or her patient breaches a perimeter or strays too far) worn on their right ankle. The surveyor reviewed Resident #18's electronic medical record (EMR). Review of Resident #18's Face Sheet (FS) (a one-page summary of important information about the patient) reflected that the resident was admitted to the facility on [DATE] with diagnosis that included but…

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 #NJ00158121 Based on observation, interview, and record review it was determined that the facility failed to develop a comprehensive, person-centered care plan for 1 of 20 residents reviewed for comprehensive care plans (Resident #270). This deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid (paper and electronic) medical record of Resident #270 which revealed the following: The admission Minimum Data Set (MDS), an assessment tool to facilitate care, dated 7/29/22, indicated the resident had diagnoses that included but were not limited to, heart failure, hypertension, Diabetes Mellitus, and End Stage Renal Disease. The facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored an 8 out of 15 which indicated that the resident had moderate cognitive impairment. The MDS documented the resident was totally dependent with eating, bathing, and locomotion. Resident #270 also required extensive assistance with transfers and bed mobility. A review of the resident's care plan (CP)…

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 revise a resident's comprehensive care plan for 2 of 20 residents reviewed, Resident #54 and Resident #8. This deficient practice was identified by the following: 1. On 11/28/23 at 11:40 AM, the surveyor observed Resident #54 in the day room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #54's hybrid medical records. The admission Record (AR) reflected that Resident #54 was admitted to the facility with medical diagnoses which included but was not limited to Dementia, Hypertension, Type 2 Diabetes Mellitus and Hyperlipidemia. According to Resident #54's Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 10/27/23, the Brief Interview for Mental Status was not conducted due to the resident's cognitive status which revealed that the resident had memory problems with both short-term and long- term memory. Further review of the Q/MDS under Section J1800 for any falls since…

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 #: NJ00162986 Based on observation, interview, and record review it was determined the facility failed to consistently follow standards of clinical practice with regards to: accurately documenting the administration of medication for 4 out of 20 residents, Resident #24, #36, and #58 as well as transcribing a physician's order for blood work for 1 out of 20 residents reviewed, Resident #8. 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…

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, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least once every sixty days. This deficient practice was identified for 2 of 20 (Resident #8 and Resident #1) reviewed for physician visits and was evidenced by the following: 1. On 11/28/23 at 11:48 AM, the surveyor observed Resident #8 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #8's hybrid medical records. The admission Record (AR) (an admission summary) reflected that Resident #8 was admitted to the facility with medical diagnoses which included but were not limited to Peripheral Vascular Disease, Absence of right leg above knee, Congestive Heart Failure and Atrial Fibrillation. A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, dated 10/14/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15…

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 #: NJ00162986 Based on observation, interview, and record review, it was determined that the, monitored, and reviewed. This deficient practice was identified for 2 of 2 units reviewed during unit inspections. This deficient practice was evidence by the following: 1. On 11/28/23 at 10:00 AM, the surveyor proceeded to perform unit inspections of the facility. While on the [NAME] Unit, the surveyor examined the declining Controlled Medication Utilization Record (CMUR) sheet for Oxycontin 10 mg belonging to Resident #2. The medication was delivered by the provider pharmacy to the facility on 8/18/23. The CMUR documented that on 9/2/23 there were no more tablets left. The CMUR then had an additional line signed with a date of 9/18/23 that there was 1 tablet left in the inventory. The surveyor interviewed the Licensed Practical Nurse (LPN) #1 who was utilizing the medication cart and asked to see the medication. When LPN#1 inspected the locked control substance area, she could not find the one tablet 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, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices of appropriately performing hand hygiene and disinfection of a blood pressure cuff used during medication administration for 1 of 4 nursing staff members observed during medication passage on 1 of 2 units observed. This deficient practice was evidenced by the following: On 11/30/23 at 9:02 AM, the surveyor observed Registered Nurse # 1(RN#1) administer medication to Resident #41. RN#1 sanitized his hands with alcohol-based hand rub (ABHR) appropriately before entering the room to check the resident's blood pressure. RN#1 did not disinfect the blood pressure machine prior to entering the room and checking Resident #41's blood pressure. Prior to exiting Resident #41's room, RN#1 went to wash his hands at the resident's sink. RN#1 placed paper towels on the side of the sink and turned on the water faucet. He applied soap, wet his hands with water, lathered his hands for 6 seconds outside the running water prior to…

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 and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) 4 of 4 Certified Nursing Aides (CNA) received their annual performance reviews and any necessary education based on the performance reviews, and b.) 2 of 4 CNA staff were educated on abuse prevention and Dementia care in accordance with requirements. This deficient practice affects all residents in the facility and was evidenced by the following: On 3/8/22, the surveyor reviewed four random CNA files for mandatory in-service education and their performance evaluation. There were 4 of 4 CNAs that did not meet the required 12 hours mandatory annual education requirements. There were 2 of 4 CNAs did not receive education on abuse prevention and Dementia care. There were no evidence of annual performance review for 4 of 4 CNA. On 3/8/22 at 1:35 PM, the surveyor interviewed the Clinical Lead Specialist Registered Nurse (CLSRN) who stated that the Director of Nursing (DON) or a designee was responsible for conducting annual performance review and the Nurse Educator (NE)…

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.

REFER to F730, F867, and F880 Based on observations, interviews, review of medical records, and review of facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) also known as the Center Executive Director failed to ensure that the facility policies were implemented, the Centers for Medicare and Medicaid Services (CMS) requirements and the US Centers for Disease Control and Prevention (CDC) guidance were followed to ensure residents rights were observed and a quality of care was provided to the facility residents in accordance with regulatory standards. This deficient practice has the potential to affect all 68 of 68 residents on their facility-wide census. The evidence was as follows: 1. On 3/07/22 at 12:50 PM, the surveyor interviewed the Center Executive Director (CED), CED in the presence of the survey team, the Clinical Lead Specialist Registered Nurse (CLSRN), and the Director and Assistant Director of Nursing from a sister facility. The CED stated that we have been informing Resident#26 about a room change since the summer and I…

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 pertinent facility documents, it was determined that the facility failed to: a.) identify, develop and implement a Quality Assurance Performance Improvement Plan as a means to self-identify and correct deficient practices, and b.) provide accurate accountability and evidence of quarterly Quality Assurance and Performance Improvement meetings for 3 of 3 quarters reviewed (July 2021, October 2021, and January 2022). This deficient practice was evidenced by the following: On 2/28/22 at 10:04 AM, during the entrance conference meeting of the surveyor and the Licensed Nursing Home Administrator/Center Executive Director (CED). The surveyor requested a copy of the Quality Assurance Performance Improvement (QAPI) Plan, the QAPI Policy and the last three quarters QAPI meeting sign-in sheets for attendance accountability. The CED stated that he will get back to the surveyor. On 3/02/22 at 9:30 AM, the surveyor still had not received the documents requested from entranc and asked the CED again for the QAPI Plan, the QAPI Policy and the last…

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 and interview it was determined that the facility failed to allow Residents #14, #17, #18, and #28 the right to dine in the facility main dining room meals. This was identified in 4 of 4 residents interviewed for dining and was evidenced by the following: On 02/28/22 at 12:25 PM, during lunch observation on the East wing of the facility, the residents were observed in their rooms having lunch. The residents who required staff assistance were having lunch in the day room on the unit. On 02/28/22 at 12:40 PM, the surveyor observed the facility's main dining room located off the main lobby between the East and [NAME] wings. The main dining room was dark and empty. On 03/02/22 at 10 AM, the surveyor conducted Resident Council meeting in the main dining room with four residents, Resident#14, #17, #18, and #28 . Four of the four residents voiced that they wanted to eat in dining room, and it had been missed. All residents told the surveyor they didn't understand why they weren't allowed as they were fully vaccinated. On 03/03/22 at 10:54 AM, a surveyor interviewed 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 a review of facility records, it was determined that the facility failed to ensure an accurate inventory of controlled medications (narcotic medications) dispensed from the facility's automated medication dispensing system (AMDS). The deficient practice was observed for 1 of 1 on the automatic medication dispensing system located in the facility's Nursing office and was evidenced by the following: On 3/1/22 at 11:30 AM, the surveyor requested the controlled substances count sheet (CSC) for the facility AMDS for the month of February 2022 from the covering Director of Nursing (DON). On 3/2/22 at 9:45 AM, the surveyor asked the covering DON if she was able to locate the CSC sheets from February 2022. She provided the surveyor with the CSC sheet from 3/1/22. The covering DON informed the surveyor that she was still looking for the February 2022 CSC sheet. She stated that the AMDS controlled substance counts are done once a day and two nurses must sign off that the counts were accurate. On 3/3/22 at 9:30 AM, the surveyor requested the CSC sheet 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: a) notify the Local Health Department (LHD) of the facility's COVID-19 outbreak for 2 of 2 ocassions on 2/14/22 and 2/15/22, b.) ensure that the facility staff was educated about infection control and other infection control mandates, and c.) ensure that the residents were monitored for COVID-19 for 9 of 9 residents reviewed (Resident#50, 14, 36, 11, 32, 24, 21, 16, and 41) according to facility policy and in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 2/2/22, included Educate residents, HCP, and visitors about SARS-CoV-2, current precautions being taken in the facility, and actions they should take to protect themselves. Regularly review CDC's Interim Infection Control…

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 that the facility failed to implement a procedure for staff testing for COVID-19 for 15 of 36 staff and further testing in accordance with nationally accepted guidelines for infection prevention and control of COVID-19 and facility policy. This deficient was evidenced by the following: According to the U.S. CDC guidelines, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 2/2/22, included New Infection in Healthcare Personnel or Residents .All HCP who have a higher-risk exposure and residents who have had close contacts, regardless of vaccination status, should be tested as described in the testing section If testing of close contacts reveals additional HCP or residents with SARS-CoV-2 infection, contact tracing should be continued .A facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility) approach should be…

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 provide documented evidence that a resident was notified in advance and in writing of two room changes with rationales for the changes. This was evidenced for 1 out of 1 resident reviewed for room changes (Resident # 26). This deficient practice was evidenced by the following: On 2/28/22 at 12:02 PM, the surveyor observed Resident #26 in bed, alert and willing to be interviewed. Resident #26 stated that he/she was previously in room [ROOM NUMBER]P which was a private room. The resident further stated that after returning from a doctor's appointment he/she was not returned back to room [ROOM NUMBER]P and was transferred to a semi-private room [ROOM NUMBER]B. The resident stated that there was no prior notification of the room change and the reason for the transfer. Resident #26 stated that he/she was satisfied with the current room status and roommate. The resident also stated that he/she…

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 resident and facility staff interviews it was determined the facility failed to allow for open visitation which included children under the age of 18 for Resident #18, 1 of 4 residents interviewed for visitation and was evidenced by the following: On 03/02/22 at 10:00 AM, the surveyor conducted a resident council meeting. Resident #18 told the surveyor that their grandson had not been allowed to visit since the pandemic. Resident #18 stated the facility said no visitor under the age of 18. Resident #18 told the surveyor, The administrator does not like children. A review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 8/23/21, Section I, titled medical diagnoses showed the resident had medical diagnoses which included Diabetes, Heart failure, and High blood pressure, with a Brief Interview of Mental Status score of 14, meaning the resident was cognitively intact. On 03/02/22 at 11:03 AM, the surveyor interviewed the facility receptionist regarding visitation. The receptionist was responsible for letting people in the building 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, review of medical records, and other pertinent facility documents, it was determined that the facility failed to notify the representative of the New Jersey Long Term Care Ombudsman about the resident's transfer to the hospital. The deficient practice was identified for 2 of 2 residents reviewed for notifications during hospitalization, Residents #43 and #36. The deficient practice was evidenced by the following: 1. A review of resident's admission Record face sheet indicated that Resident #43 had diagnoses which included but were not limited to: End stage renal disease, Hypertension and Pulmonary fibrosis. A review of the Significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/15/21 revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. A review of the nurse's notes (NN) dated 11/8/21 at 07:37 PM revealed that Resident #43 was admitted to the hospital with 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.

Based on interview and record review, it was determined that the facility failed to provide written notification of the facility's policy for bed hold to the resident/resident's representative at the time of transfer from the facility to the hospital. This deficient practice occurred to 1 of 1 resident reviewed, Resident#36 for hospitalization and was evidenced by the following: A review of the admission Record (an admission summary) reflected that Resident #36 was admitted in the facility with diagnoses which included but not limited to Heart failure, Gastrostomy status, and Type 2 Diabetes mellitus without complications. It was also indicated that the resident had family listed on contact list. A review of the 12/15/21, Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, indicated a Brief Interview for Mental Status (BIMS) score of 8, which reflected that the resident's cognition was moderately impaired. A review of nurse's notes dated 2/3/22 reflected that the resident was discharged to the hospital from the facility for peg tube…

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 the facility failed to complete weekly wound measurements and wound assessments per facility policy for 1 of 1 resident, Resident#16 reviewed for skin conditions and was evidenced by the following: On 02/28/22 at10:36 AM, during the initial tour of the facility Resident #16 told the surveyor that they had venous wounds on the left foot and the facility wound doctor had not been in to see the resident since January. Resident #16 told surveyor Before January, the wound doctor would see me every week. A review of the resident's medical records included diagnosis of Peripheral vascular disease, hypertension, absence of right leg above knee and cellulitis of left lower limb. A review of the Annual Minimum Data Set, an assessment tool used to facilitate care dated 11/23/21, indicated the resident had a Brief Interview of Mental Status of 15, meaning the resident was cognitively intact. On 03/01/22 at 09:46 AM, the surveyor reviewed the active physician order with a start date of 2/13/22 which included the following wound…

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 other pertinent facility documents, it was determined that the facility failed to appropriately monitored and assessed wound for 1 of 1 resident, Resident#59's reviewed according to facility policy for pressure ulcer. This deficient practice was identified and was evidenced by the following: On 3/1/22 at 11:59 AM, the surveyor observed Resident#59 in the room lying in bed, awake, alert and verbally responsive. A review of the admission Record (an admission summary) reflected that Resident#59 was admitted in the facility on 10/21/21 and had diagnoses which included but not limited to Multiple sclerosis (MS), a chronic disease affecting the brain and spinal cord, and can cause problems with vision, balance, and muscle control and Pressure ulcer of sacral region stage 4. A review of the 1/27/22, Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, indicated a Brief Interview for Mental Status (BIMS) score of 14, which reflected that the resident's cognition was intact. It also reflected that…

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 post the nurse staffing information on 2 of 3 areas of the facility in a prominent place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 2/28/22 at 9:00 AM, upon entry into the facility the surveyors did not observe that there was a Nurse Staffing Report (NSR) displayed in the facility lobby. On 2/28/22 at 9:30 AM, the surveyor toured the [NAME] wing nursing unit, the surveyor was unable to observe the facility daily NSR and schedule. The Licensed Nursing Home Administrator/Center Executive Director (CED) informed the survey team that there were two nursing units, the East and [NAME] wing. On 3/3/22 at 8:59 AM, the surveyor team interviewed the facility Staffing Coordinator (SC). The SC informed the survey team that part of her job is to post the daily NSR in the lobby area and Ns schedule at the East wing unit. She stated that she will post the daily Ns on the East Wing in a display cabinet next to 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 Infection Preventionist (IP) has completed specialized training in infection prevention and control and qualified by certification for 1 of 1 staff in accordance with the facility policy and Center for Medicare and Medicaid Services (CMS) and New Jersey (NJ) guidelines. This deficient practice was evidenced by the following: According to the NJ Executive Directive 20-26 for a LTCF (Long Term Care Facility) included iii. The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPC program On 2/28/22 at 10:04 AM, the surveyor met with the Licensed Nursing Home Administrator/Center Executive Director (CED) during the entrance conference and informed the surveyor that he had been working in the facility for 8 months and that the Director of Nursing (DON) for at least a year. The CED stated that the DON was not at the facility for two weeks now. The surveyor asked the CED for a copy of 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.