Childrens Specialized Hospital Mountainside

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to consistently maintain appropriate infection control practices to limit the spread of infection. The deficient practice was observed with 1 (one) staff person and 1 resident (Resident#7) in room [ROOM NUMBER] during the medication pass observation. This deficient practice was evidenced by the following: On 1/21/26 at 9:51 AM, the surveyor observed the Registered Nurse (RN) wearing a pair of gloves. The RN was observed preparing medications using a syringe. After the medication was prepared, she administered all the medication to Resident #7 by G-Tube (Gastrostomy tube, a small tube surgically inserted into the abdomen directly into the stomach to deliver nutrition, fluids, and medication). [...]

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods (PHF) in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 9/24/24 at 10:30 AM, in the presence of the Assistant Dietary Manager (ADM), the surveyor observed the following: In the walk-in refrigerator, the surveyor observed the following: -a 1/4 size steam table pan which contained green beans in a liquid with a sticker on the top of the container that indicated a use by date of 9/20/24, -an opened, half used package of sliced salami with no use by date on it, - an opened, half used package of un-sliced beef bacon with no use by date on it, In the reach in cheese refrigerator, the surveyor observed the following: [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure a.) a physician orders for administration was followed, route of administration was clarified (Resident 18), and b.) dosing was clarified for an eye ointment, prior to administration (Resident 44 and Resident #2) in accordance with professional standards of practice and facility policy. The deficient practice was identified for three (3) of seven (7) residents, administered by three (3) of five (5) nurses, observed during the medication administration observation, 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 wroteComplaint # NJ175565 Based on observations, interviews, medical record review, and other pertinent facility documents on 07/18/2024 and 07/19/2024, it was determined that the facility who has been in an active outbreak of the Multi-Drug Resistant Organism (MDRO) of Carbapenem-Resistant Acinetobacter baumannii (CRAB - bacteria resistant to nearly all antibiotics and difficult to control and irradicate from the environment) failed to provide documentation in the residents' medical records of consents, declinations, and family education for CRAB testing. This deficient practice was identified for 51 out of 54 residents and evidenced by the followng: During an interview with the Surveyor on 07/18/2024 at 1:03 P.M., the Advanced Practice Nurse (APN) stated she did obtain some consents for CRAB testing from parents and guardians through emails and phone calls. [...]

Inspectors wroteComplaint # NJ175565 Based on observations, interviews, medical record review and review of other facility documentation on 07/19/2024, it was determined that the facility failed to implement appropriate infection control measures for the storage of respiratory equipment. This deficient practice was identified for 1 of 6 resident rooms observed for infection control. This deficient practice was evidenced by the following: 1.) During a tour of a resident room on North Wing of facility unit on 07/19/2024 at 12:11P.M., the Surveyor observed ventilator connector and tubing on the floor of room. During an interview with the Surveyor on 07/19/2024 at 12:13 P.M., the Registered Nurse (RN) confirmed the ventilator connector and tubing was on the floor in the room. The RN further stated that the ventilator connector and tubing should not be on the floor. [...]

Inspectors wroteBased 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 12 of 21 residents, (Residents #2, #3, #11, #14, #21, #27, #28, #33, #36, #41, #44, and #48) reviewed, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set 3.0 Public Reports page last modified 12/01/21, included that the MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. [...]

Inspectors wroteBased on the interview, record review, and review of the facility provided documents, it was determined that the facility failed to identify medication irregularity during the monthly MRR (Medication Record Review) of the CP (Consultant Pharmacist) for three (3) of five (5) residents reviewed for unnecessary medications, Residents#14, #24, and #28. This deficient practice was evidenced by the following: According to [NAME]-Drugs (or Lexicomp an evidenced-based drug referential content; that provides evidence and recommendations to help clinicians as they treat and advise patients with complex conditions) included that review of the Erythromycin with pharmacologic category of antibiotic; Gastroparesis (off-label use; gastoparesis is a condition that affects the normal spontaneous movement of the muscles in stomach). [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure a) proper disposal of a controlled substance (narcotic; medications, that due to their high potential for abuse, are tracked with detail) medications, b) medication was crushed, c) proper disposal of non-controlled substance and was identified during the medication administration observation for two of three nurses in accordance to standards 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: [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to ensure a) that a physician's wound care order was followed and clarified, b) provide wound care in accordance with the facility's policy and professional standards of clinical practice for 1 (one ) of 2 (two) residents (Resident #3) reviewed for pressure ulcers. 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 state: [...]