Complete Care at West Caldwell LLC

Inspectors wroteBased on interviews and review of pertinent facility documents on [DATE], it was determined that the facility failed to complete and thoroughly investigate the fall incident of a cognitively impaired resident (Resident #5) to rule out abuse and neglect. On [DATE] the resident was found unresponsive on the floor next to their bed with their head in the trash bin lined with clear plastic bag. The facility called 911 and police came. The resident was pronounced dead by EMS [emergency medical services] at bedside. This deficient practice was identified for 1 of 5 residents reviewed and was evidenced by the following:The surveyor reviewed the medical record for Resident #5. [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure that there was a Licensed Nursing Home Administrator (LNHA) who was licensed in New Jersey (NJ), who was actively involved in daily oversight to ensure all policies and procedures were implemented and followed in the facility to ensure the residents' physical and psychosocial care needs were met. Refer to F 837 F The evidence was as follows: On 3/17/25 at 8:28 AM, the surveyor observed a posted chain of command on a bulletin board within the facility's entrance that had the Acting Administrator (AA) at the top of list with the letters LNHA and MPA (Master of Public Administration) next to his name. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that the Governing Body (GB) appointed a Licensed Nursing Home Administrator (LNHA) who was actively licensed in the state of New Jersey (NJ) to implement the facility's policies and procedures to ensure the residents' physical and psychosocial care needs were met. Refer to F 835 F The evidence was as follows: On 3/17/25 at 8:28 AM, the surveyor observed a posting of the chain of command in the facility's entrance. The Acting Administrator (AA) was listed at the top of the list with the letters LNHA and MPA (Master of Public Administration) next to his name. On 3/17/25 at 9:10 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the facility's administrator was the AA, and that he was stuck in traffic, but he was on the way to the facility. [...]

Inspectors wroteNJ 163118 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to adjust medication administration times to accommodate for scheduled dialysis times. This deficient practice was identified for 1 of 2 resident (Resident #341) reviewed for dialysis and was evidenced by the following: On 3/18/25 at 12:49 PM, the surveyor reviewed the closed records for Resident #341. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; end stage renal (kidney) disease, chronic kidney diseases and diabetes mellitus with diabetic polyneuropathy (multiple nerves throughout the body become damaged or dysfunctional). [...]

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 1 of 5 residents, Residents #4, reviewed for immunization status. This deficient practice was evidenced by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 10/26/24, included the following. The CDC recommended administration of Pneumococcal conjugate vaccine (PCV20 or PCV21) at least 1 year for all adults 50 years or older who have received PCV 13 only at any age. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure a pain management regimen was followed in accordance with physician orders. This deficient practice was identified in 1 of 3 residents reviewed for pain (Resident #2). This deficient practice was evidenced by the following: On 3/17/25 at 9:43 AM, during the initial tour of the facility Resident was observed in bed covered with a blanket. The resident stated that their teeth hurt and may have received pain medication at 6:00 AM that morning. The surveyor reviewed Resident #2's admission Record (an admission summary) which showed that Resident #2 was admitted to the facility with diagnoses which included but were not limited to: [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to ensure the Consultant Pharmacist identified a drug, Levothyroxine for hypothyroidism was spaced 4 hours apart from Calcium Carbonate, in accordance with manufacturer's specifications. This deficient practice was identified for 1 of 5 residents (Resident #4) reviewed for unnecessary medications and was evidenced by the following: Reference: According to the manufacturer's specifications for Levoxyl (Levothyroxine) section 7. Drug Interactions, under table 2. Calcium Carbonate may form an insoluble chelate with levothyroxine, . Administer Levoxyl at least 4 hours apart from these agents. Reference: According to the manufacturer's specifications for Synthroid (Levothyroxine) section 7. Drug Interactions, under table 2. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that medication were administered according to physician orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing Statues for 1 of 23 residents (Resident #33) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statues Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that hand hygiene was performed to prevent the spread of infection. This deficient practice was identified for 1 (occupational therapist) of 10 facility staff members reviewed for hand hygiene. This deficient practice was evidenced by the following: On 10/22/20 at 10:58 AM, the surveyor observed an occupational therapist exiting room # 231 which was a cohort room to observe for symptoms of COVID-19. The occupational therapist did not perform hand hygiene when she exited the room or when she exited the observation unit for new or re-admissions. On that same day, the surveyor interviewed the occupational therapist who stated I felt I was not in contact with the resident. [...]