Allendale Rehabilitation and Healthcare Center

Inspectors wroteBased on observations, interviews, record reviews, and reviews of facility policies, the facility failed to ensure Infection Control measures were maintained 1. during incontinent care for one resident (Resident (R) 5) of one resident reviewed for incontinent care in a total sample of 29 residents, 2. during separation of clean and soiled laundry, and 3. in a water management program for Legionella bacteria. These failures placed residents at risk of cross-contamination of bacteria and increased health complications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure an abnormal involuntary movement scale (AIMS-a scoring system which uses a 0-4 rating scale for 12 items to assess the severity of the abnormal involuntary movements) was accurate and completed timely for three residents (Residents (R)10, R15, and R4) reviewed in a sample of29 residents. This failure placed residents at risk of not receiving care and services related to their psychiatric illnesses.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure the admission PASARR (Pre-Admssion Screening and Resident Review-a mandatory review prior to admission to screen for mental illness and intellectual disabilities) was accurate for one resident (Resident (R)10) of two residents reviewed for PASARR in a total sample of 29 residents. This failure placed residents at risk of not receiving the appropriate mental health services.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure hair washing was provided during showers for one resident (Resident (R) 49) of four residents reviewed for ADLs (Activities of Daily Living) in a total sample of 29 residents. This failure placed the residents at risk of a diminished quality of life.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide timely repositioning for one (Resident (R)5) of two residents reviewed for positioning in a total sample of 29 residents. This failure placed the resident at risk of skin breakdown.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy, the facility failed to utilize the physician ordered hand splints or a hand roll for two of two residents (Residents (R) 5 and R81) reviewed for contractures in a total sample of 29. This failure placed the residents at risk of further decreased range of motion (ROM) and worsening contractures (a condition of shortening and hardening of muscles, tendons, and other tissue, often leading to deformity and rigidity of joints.)

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; documented discussion related to risk versus benefits; and signed informed consent prior to bed rail use for one of four residents (Resident (R)68) reviewed for side rails out of 29 sampled residents. The lack of alternate side rail measures and proper assessment/consent increased the potential for restraint or side rail entrapment.

Inspectors wroteBased on observation, interview, record review, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 6/13/24 at 9:15 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: Upon entering the kitchen the surveyor observed the FSD and Dietary Aide #1 (DA#1) both wearing earrings that hung more than one inch (in) from their earlobes. The FSD acknowledged both she/he and DA#1 were wearing jewelry that was prohibited in the kitchen area. [...]

Inspectors wroteNJ#162614 Based on observations, interviews, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to report as required to the New Jersey Department of Health (NJDOH) within two hours an allegation of abuse for one (1) of two (2) residents (Resident #156) reviewed for abuse. This deficient practice was evidenced by the following: On 6/13/24 at 11:20 AM, the surveyor reviewed a Reportable Event Record (RER) for a resident to resident abuse that indicated the RER was submitted to the NJDOH by the facility's Administrator at that time, on 3/20/23. A review of the RER included the following: Today's Date: 3/20/23 Date of Event: 3/18/23 Time of Event: 11:00 PM The section that the facility can document if the incident was a significant event and if the event was called in was blank. [...]

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide the resident or resident representative appropriate written notification of the facility's bed hold and reserve payment policy upon transfer to the hospital for two (2) of two (2) residents (Resident #69 and #85) reviewed for hospitalizations. The deficient practice was evidenced by the following: 1. A review of Resident #69's hybrid (combination of paper and electronic) medical record revealed the following: Resident #69's two discharge assessment-return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, reflected that the resident was transferred to the hospital. [...]

Inspectors wroteBased on observation, interview, and record review 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, in accordance with federal guidelines for three (3) of twenty four (24) residents, Resident #69, Resident #105 and Resident #306 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 6/13/24 at 10:31 AM, Surveyor #1 (S#1) observed Resident #69 seated in a wheelchair calling for the nurse. The Licensed Practical Nurse (LPN) stated to the surveyor that Resident #69 had just returned from dialysis. On 6/13/24 at 01:00 PM, S#1 reviewed Resident #69's medical record. [...]

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for one (1) of one (1) resident (Resident #3) reviewed for PASRR. This deficient practice was evidenced by the following: On 6/13/24 at 10:20 AM, the surveyor observed Resident #3 lying in bed in their room. The resident was alert and oriented. The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #3 which revealed the following: According to the admission Record (AR, an admission summary), Resident #3 had diagnoses that included but were not limited to, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), anxiety disorder, major depressive disorder, and paranoid schizophrenia (a type of delusion that usually involves persecution). [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to consistently follow standards of clinical practice with regards to accurately: a) documenting medication administration for one (1) of 24 residents, Resident #18, reviewed for insulin medications, b) complete dialysis post assessment forms for one (1) of one (1) resident, Resident #69, reviewed for dialysis, and c) complete behavior monitoring sheets for one (1) of five (5) residents, Resident #50, reviewed for unnecessary medications. 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: [...]

Inspectors wroteBased on observation, interviews, record review, and review of facility policies, it was determined that the facility failed to identify and accurately address an Enteral Feeding (EF) order discrepancy. This deficient practice was identified for one (1) of two (2) residents reviewed for EF (Resident #27). The deficient practice was evidenced by the following: On 6/13/24 at 10:24 AM, the surveyor interviewed Resident #27 in the resident's room. The resident stated he/she does not take eat by mouth and receives a tube feeding (TF, an EF, is a way of delivering nutrition directly to stomach or small intestine). On 6/14/24 at 9:04 AM, the surveyor reviewed Resident #27's hybrid (paper and electronic) medical record which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the Consultant Pharmacist (CP) failed to clarify medication route for a resident during the monthly medication (med) reviews for one (1) of six (6) Residents, Resident #27. The deficient practice was evidenced by the following: On 6/13/24 at 10:24 AM, the surveyor interviewed Resident #27 in the resident's room. The resident stated he/she does not take any medications (meds) by mouth. On 6/14/24 at 9:04 AM, the surveyor reviewed Resident #27's hybrid (paper and electronic) medical record which revealed the following: Resident #27's admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteBased on interview and review of pertinent facility provided documentation, it was determined that the facility failed to ensure that the employed designated Infection Preventionist (IP) had completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance prior to assuming the IP role for one (1) of one (1) employee reviewed for IP. This deficient practice was evidenced by the following: On 6/14/24 at 12:10 PM, the surveyor reviewed the facility provided signed job description for the IP which listed the date of hire as 6/10/21. The IP's job description included the following Educational and Certification Requirements: The IP's job description included the following acknowledgement that was signed by the IP and dated 6/10/21: [...]

Inspectors wroteCOMPLAINT # NJ171657 Based on interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This deficient practice was identified for one (1) of two (2) residents reviewed, Resident # 157. This deficient practice was evidenced by the following: On 6/17/24 at 12:10 PM, the surveyor in the company of another surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Regional Director of Operations/Registered Nurse (RDoO/RN) who explained that the investigation involves a look back of 48 hours, including statements from staff who cared for the resident. The surveyor reviewed the medical records of Resident #157 and revealed the following: [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to assure the Licensed Nursing Home Administrator (LNHA) attended the quarterly Quality Assurance (QA) meetings. This was identified for 2 of the 3 QA meetings reviewed. This deficient practice was evidenced by the following: On 10/07/22 at 10:27 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the sign-in sheets for the last three QA meetings and showed the following: 1/27/22 (1st Quarterly QA Meeting)=attendees included an Infection Preventionist Nurse (IPN), Medical Director (MD), and the Director of Nursing (DON). 4/6/22 (2nd Quarterly QA Meeting)=attendees included IPN, LNHA, and the DON. 7/7/22 (3rd Quarterly QA Meeting)=attendees included IPN and DON. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accommodate a resident's need and provide a functioning air conditioner. This deficient practice was identified for Resident # 75, 1 of 18 residents reviewed for the accommodation of needs, and was evidenced by the following: On 9/28/22 at 12:29 PM, during an initial tour of the facility, the surveyor met with resident #75, who was in the bed. During the interview, the resident told the surveyor that he/she had no air conditioning throughout the summer. Resident #75 said that the Certified Nursing Assistants (CNAs) and the nurses were also complaining about the heat in the room. On that same date and time, the surveyor asked the resident if anyone was notified such as maintenance and Resident #75 said yes and was told that a new air conditioner was ordered but it never arrived. [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to develop a comprehensive person-centered care plan to include resident preferences for 1 of 3 residents, Resident #4, reviewed for the resident council meeting and was evidenced by the following: On 9/29/22 at 10:30 AM, the surveyor conducted a Resident Council Meeting at the facility. Three residents attended the meeting that included Resident #4. On 9/29/22 at 11:21 AM, following a resident council meeting, Resident #4 stated that there was an incident a month and a half ago that happened between the resident and the nurse. The resident stated that he/she did not like the nurse. The resident further stated that the incident was reported to the previous Licensed Nursing Home Administrator (LNHA) and the Social Worker (SW). The resident indicated it was investigated. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 1 of 4 medication carts inspected. This deficient practice was evidenced by the following: On 10/03/22 at 11:33 AM, the surveyor inspected the South Middle med cart in the presence of a Registered Nurse (RN). The surveyor observed two opened boxes of Ipratropium bromide/ Albuterol Solution 0.5-2.5, 3 ml vials (Medication for breathing) that belong to two residents, Residents#72 and #183 that were discharged from the facility. The surveyor interviewed the RN who stated that both residents were discharged from the facility and were not able to tell the surveyor when they will be returning to the facility. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documentation, it was determined that the facility failed to ensure a.) that staff handle clean linens and towels appropriately to prevent contamination and b.) all staff entering the building were screened for Covid-19 signs and symptoms in accordance with the facility policy Covid-19 Employee Screening and Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/23/22, reflected 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic . [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a safe and sanitary environment in the folding and laundry rooms in accordance with the facility's policy. This deficient practice was evidenced by the following: On 10/06/22 at 9:10 AM, two surveyors interviewed Laundry Aide #1 (LA#1) who was in the room with folded and stacked linens. She informed the surveyors that the room was the folding area, where they folded the clean linens. The surveyors observed a table in the room. LA#1 stated that they utilized the table for folding the clean linens. On that same date and time, during the interview of the surveyors, LA#2 entered the room. LA#1 and #2 stated that the folding room was a clean room. [...]