Alaris Health at Kearny

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation practices as well as store, and label in a manner intended to prevent the spread of food borne illness for 2 of 2 days of kitchen observation. This deficient practice was evidenced by the following: On 2/5/26 at 9:48 AM, the surveyor, in the presence of the Food Service Director (FSD), and the Regional Director, toured the 3rd Floor kitchen. The FSD stated the main kitchen was offsite and arrived as cooked at the facility. The FSD further stated that the facility utilized the steam table, temperatures were taken and then food was served to the residents. The FSD also stated that the facility had two satellite kitchens, one on each floor (3rd and 4th). [...]

Inspectors wroteBased on interview, and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for 1 of 17 newly hired licensed staff reviewed, Staff Member (SM) #35 evidenced by the following: On 2/5/26 at 9:56 AM, during entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the personnel files of the facility's 36 new hire employees since their last recertification survey. A review of the facility provided documents, 1 of 17 licensed staff personnel files included the following:SM #35, a Registered Nurse (RN), with a date of hire (doh) of 1/30/26, had a License Verification Report which was dated 2/1/26. There was no documented evidence that SM #35's license was verified prior to the doh. [...]

Inspectors wroteBased on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the Resident or Resident Representative with written notification of the facility's bed hold policy for 1 of 2 residents, (Residents #126), reviewed for hospitalizations. This deficient practice was evidenced by the following: The surveyor reviewed the medical records of Resident #126, and revealed the following: The admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately complete a portion of the Minimum Data Set (MDS), an assessment tool that facilitate the plan of care, to accurately reflect the resident's status for 1 of 26 residents reviewed (Resident #2). The deficient practice was evidenced by the following:On 2/5/26 at 11:54 AM, Surveyor #1 (S #1) observed Resident #2 being wheeled into the resident's room coming from an activity. The resident stated that they were okay. On 2/9/26 at 12:25 PM, Surveyor #2 (S #2) was given the assignment sheet in which indicated Resident #2 was on the list as a feeder. On 2/9/26 at 12:36 PM, S #2 observed Resident #2 seating in the wheelchair with lunch tray untouched and uncovered. [...]

Inspectors wroteBased on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to ensure a resident with severe cognitive impairment, who was at risk for elopement and had a known history of wandering was appropriately supervised and monitored to ensure safety, prevent elopement, and/or exiting of the building for 1 of 1 resident reviewed for elopement (Resident #44). This deficient practice was evidenced by the following: On 2/5/26 at 10:25 AM, the surveyor observed Resident #44 asleep in their bed. A review of Resident #44'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; [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, the facility failed to ensure the indwelling urinary catheter drainage tubing was stored in a manner to prevent Urinary Tract Infection (UTI) for 1 of 1 resident reviewed for urinary catheter care or UTI (Resident #88). The deficient practice was evidenced by the following: On 2/5/26 at 10:46 AM, the surveyor observed Resident #88 seated in a wheelchair (w/c) in their room with a visitor seated in the room. There were no staff members in the room. The surveyor observed that there was a urinary catheter tubing and drainage bag that was hung on the side of the bed that was not connected to Resident #88. Further observation of the tubing that was leaning against part of the bed frame reflected that the end of the tubing was not capped. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to a.) ensure that the comprehensive care plan and nursing documentation were updated to reflect a physician's order for oxygen therapy for 1 of 2 residents (Resident #9) and b.) ensure that a resident receiving oxygen therapy had their oxygen saturation monitored as a standard of practice for 1 of 2 residents (Resident #11) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 2/10/26 at 10:55 AM, Surveyor #1 (S #1) observed Resident #9 was lying in bed with oxygen (O2) in place via nasal cannula (n/c) at 2 liters per minute (2LPM) delivered by concentrator. The O2 tubing and humidifier on the O2 concentrator were labeled. S #1 reviewed the medical records of Resident #9 and revealed: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times to accommodate for dialysis scheduled times and documenting accurate medication administration times. This deficient practice was identified for 1 of 2 residents, (Resident #12), reviewed for dialysis services. The deficient practice was evidence 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: [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure residents received feeding assistance in accordance with residents' plan of care. This deficient practice was identified for 2 of 4 residents (Resident#2 and Resident #8) observed during meal time, and was evidenced by the following:1. On 2/5/26 at 10:44 AM, Surveyor #1 (S #1) observed the Nursing Home Resident Care Staffing Report (NHRCSR) for 2/5/26, 7 AM-3 PM (7-3) shift with a census of 111, and the ratio of the Certified Nursing Aid (CNA) to Resident was 1:9.3, and was posted on the 3rd floor bulletin board. [...]

Inspectors wroteBased on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure proper documentation of 3 controlled dangerous substances (CDS) medications for 3 residents; 1 Unsampled Resident (Unsampled Resident #1), Resident #44, and Resident #89, by 1 of 3 nurses observed during the medication storage task. 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: [...]

Inspectors wroteBased on interviews, record review, and review of pertinent documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication by lack of indication, reason for use or benefit versus risk analysis for 1 of 5 (Resident #6) residents reviewed for unnecessary medications. The deficient practice was evidenced by the following: The surveyor reviewed the electronic medical record (EMR) for Resident #6 which revealed the following:A review of the admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but was not limited to type 2 diabetes (high blood sugar due to the body's inability to use insulin properly) and chronic obstructive pulmonary disease (COPD)(a common lung disease causing restricted airflow). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure the menu (or diet slip) was followed and b.) ensure that residents received food and beverage in accordance with their preferences. This deficient practice was identified for 1 of 15 residents (Resident #92) observed in the dining room and 1 of 3 residents (Resident #3) observed in the 3rd floor unit during meals, and was evidenced by the following:1. On 2/6/26 11:40 AM, during lunch observation in the 4th floor dining room, the surveyor observed the Licensed Practical Nurse (LPN) was feeding Resident #92 and there was no 4 fluid ounces of whole milk served to the resident which was according to the dietary slip that was on top of the resident's table. [...]

Inspectors wroteBased 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 practices for 4 of 7 residents, (Residents #39, #52, #70, and #104) during meal observation and b.) follow appropriate hand hygiene and use of personal protective equipment (PPE) for 1 of 4 nurses (1 Registered Nurse), observed during medication administration pass (med pass), and follow appropriate infection control practices to prevent the potential 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 Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, revealed. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for a.) 1 of 2 tub (shower) rooms (3rd floor), b.) 2 of 5 residents' rooms privacy curtains (rooms [ROOM NUMBERS]), and c.)1 of 1 nourishment area observed during environmental tour. This deficient practice was evidenced by the following: 1. On 2/5/26 at 10:50 AM, the surveyor with the Registered Nurse/Unit Manager (RN/UM) toured the 3rd floor Tub Room, also known as the shower room of the residents in the unit as per the RN/UM. Both the surveyor and the RN/UM observed in the middle of the tub room the ceiling vent with accumulation of grayish substances which the RN/UM confirmed accumulation of dust, and the RN/UM stated that the Housekeeper would be notified to clean it. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to honor residents' choices to have their food warmed by staff members daily for 99 of 107 residents that received meals in the facility. This failure resulted in the residents' choices being denied.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure the call light was within reach for one of one resident (Resident (R) 69) out of a sample of 26 residents reviewed for accommodation of needs and preferences. This failure had the potential to cause R69 to have unmet care needs.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan directing measurable goals and interventions related to the use of an anticoagulant for one of five resident (Resident (R) 105) reviewed for unnecessary medications out of a total sample of 26. This failure placed the resident at risk for unmet care needs and the inability to monitor for signs and symptoms of abnormal bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with showering for one of three residents (Resident (R) 14) reviewed for activities of daily living (ADLs) out of a total sample of 26. This failure increased the potential for R14 to have unmet hygiene needs.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 51) reviewed for dialysis out of a total sample of 26 was offered a snack and/or fluids on dialysis days when away from the facility during mealtimes and failed to accurately document the resident's nutritional intake. This had the potential to cause hypoglycemic incidents and provided inaccurate data for the resident's nutritional assessments.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure staff followed physician ordered parameters for blood pressure (BP) medications for one of five residents (Resident (R) 105) reviewed for unnecessary medications. R105 received antihypertensive medications when the systolic blood pressure (SBP) was below the parameters set by the attending physician. This had the potential to cause hypotensive episodes for the resident.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment for one of 26residents (Resident (R) 63) whose beds were observed for bed rail safety out of a total sample of 26. The facility failed to ensure R63's bed rails were identified and repaired timely when broken, which had the potential to cause injury to the resident.

Inspectors wroteBased on observation interview and review of facility documentation, it was determined that the facility failed to maintain resident call bells accessible and within reach of all residents. This deficient practice occurred for 1 of 20 residents reviewed (Resident #64). This deficient practice was evidenced by the following: 1. On 10/5/22 at 11:04 AM, two surveyors observed Resident #64 in bed. Resident #64 was disoriented and confused when interviewed. The surveyors observed that the resident did not have a call bell (a bell used to call for staff assistance) within their reach. The surveyor observed that there was a plug in the wall attached to the facility's call bell system but that no wire or button was attached to the plug. The surveyor did not observe another button or bell that the resident could use to call for staff assistance. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 1 of 3 residents reviewed for resident assessment, Resident #1. This deficient practice was evidenced by the following: On 10/14/22 at 10:10 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System for Medicad/Medicare. The facility must complete and electronically transmit the MDS up to 14 days of the resident assessment completion. Resident #1 was triggered under the survey facility task as MDS record over 120 days old. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to appropriately remove, clarify, accurately administer, and document resident's physician ordered medications. This deficient practice was identified for 4 of 23 residents reviewed (Resident #22, #23, #24, #54, #73, #80, #93 and #57) 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: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to obtain a physician's order for the administration of oxygen. This deficient practice was observed for 1 of 3 residents (Resident #62) reviewed for respiratory care. This deficient practice was evidenced by the following: On 10/5/2022 at 11:20 AM, the surveyor observed Resident #62 in bed. The resident received Oxygen (O2) at four liters per minute by way of a nasal cannula attached to an oxygen concentrator (a free-standing device used to deliver oxygen). The surveyor reviewed the hybrid medical record. The admission Record indicated that the resident had medical diagnoses that included but were not limited to Unspecified Sequelae of Cerebral Infarction (stroke), COVID-19, virus not identified, Other Seizures, and Heart Failure. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to immediately notify the hospice agency about a significant change in a resident's condition and a resident's death. This deficient practice was identified for 1 of 3 residents, Resident #83, reviewed for hospice/end-of-life care. The deficient practice was evidenced by the following: The surveyor reviewed the closed medical record for Resident #83. The reviewed admission Record indicated that the resident had medical diagnoses that included but were not limited to Sepsis, Pressure Ulcer of Sacral Region, Aphasia (loss of ability to understand or express speech), Cerebral Infarction (stroke), Acute Kidney Failure, and Altered Mental Status. [...]