Daughters of Israel Pleasant Valley Home

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to sanitize and air dry steam table pans in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 3/9/26 at 11:07 AM, in the presence of the General Manager (GM) and the Executive Chef (EC), the surveyor observed the following:On the dairy side of the kitchen, on a shelf in the food preparation area, the surveyor also observed 6 spice containers with their tops opened. The GM stated these lids should be closed. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) that the physician's orders were followed according to the standard of clinical practice for 4 of 4 residents, (Resident #8, 72, 108 and 114), reviewed for respiratory care, and b.) failed to provide a humidifier according to the facility's policy and procedure for one (1) of 4 residents, (Resident #108) reviewed for respiratory care. This deficient practice was evidenced by the following:1. On 3/6/26 at 10:35 AM, the surveyor observed Resident #8 in bed in their room, receiving oxygen via a nasal cannula (NC, a plastic prong attached to a tube, inserted into the nostrils through which O2 flows) from a concentrator and the surveyor observed the oxygen flow meter was set at 3.5 liters per minute (lpm). [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices to prevent and control the spread of infection. Specifically the facility failed to: a) post required signage at the rooms for 9 of 9 residents reviewed for Enhanced Barrier Precautions (Resident #'s 1, 2, 4, 8, 12, 67, 108, 113, 114), b) failed to handle medications in a sanitary manner during medication administration observation and medication storage review by 1 of 3 nurses observed during medication administration and 1 of three nurses observed during medication storage review, and c) a failure to cleanse blood glucometer between uses by 1 of 3 nurses observed during medication administration. This deficient practice was evidenced by the following:1. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 4 of the 22 residents (Resident #19, 61, 108, and #114) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 3/6/26 at 10:33 AM, the surveyor observed Resident #19 in bed awake, alert, and able to make needs known. The surveyor observed that the resident's call device was hanging on the bed, and the resident was leaning to the opposite side of the bed, where the call bell was out of reach. Resident #19 was asking where the call device was, and they stated they cannot reach it. On the same day at 12:09 PM, the surveyor observed that the resident's call device was out of the resident's reach. [...]

Inspectors wroteBased on observation and interview it was determined the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for one resident's room (Resident # 3's room [ROOM NUMBER]) and in the hallway of the HP unit. This deficient practice was evidenced by the following: 1. On 3/6/26 at 12:32 PM, in Resident # 3's room (room [ROOM NUMBER]), the surveyor observed that approximately 10 inches of the wall paper was peeling off the wall near the bottom of the window sill. The surveyor also observed an approximately 2 inch break in the plastic corner protector on the wall in the resident's room. 2. On 03/6/26 at 11:00 AM, during the initial tour of the facility the surveyor observed the following in the hallway and common area of the HP nursing care unit: [...]

Inspectors wroteBased on interviews 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 (one) of 22 residents (Resident #108), who were reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 3/6/26 at 10:52 AM and on 3/9/26 at 10:12 AM, the surveyor observed Resident #108 awake, lying on the bed, with an indwelling catheter with a privacy bag attached to the lower side of the bed. On 3/6/26 at 1:21 PM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #108, which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure care and services were provided in accordance with professional standards of practice for 2 of 22 residents reviewed (Residents #1 and #11). Specifically, the facility failed to clarify a physician order resulting in duplicative treatment orders, accurately document completion of a treatment order for Resident # 1, and provide comprehensive insulin management for Resident # 11.

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) which was identified for 1 of 5 residents (Resident #113) reviewed for unnecessary medications. This deficient practice was evidenced by the following:On 3/9/2026 at 10:20 AM, the surveyor observed Resident #113 lying in their bed, alert, and verbally responsive. Resident #113 was receiving an enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) via a feeding pump. The resident had a urinary drainage bag covered with a urinary privacy bag, hanging from the bottom of the bed frame. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to: (a) properly store, and date medications in 1 of 4 medication carts and 1 of 2 medication storage rooms inspected; and (b) ensure controlled medications were stored in a separately locked, permanently affixed compartment in 1 of 3 medication carts inspected for medication storage. This deficient practice was evidenced by the following: 1. On [DATE] at 11:08 AM, the surveyor inspected the medication storage room on the HP unit in the presence of Licensed Practical Nurse (LPN) # 1 assigned to the unit. There were 2- 0.45% Normal Saline, one Liter intravenous bags which both had a manufacturer's expiration date of [DATE] stored in a cabinet. LPN #1 confirmed the IV bags were expired and removed them to be disposed. [...]

Inspectors wroteComplaint #: 392826 (187404)Based on observations, interviews, record review, and review of other pertinent facility provided documentation, the facility failed to ensure a.) the residents' current active care plan (CP) contained the interventions that were implemented after each resident's fall and were followed in order to prevent any additional falls for 3 of 3 residents (Residents #1, #2, and #3) reviewed for accidents and falls and b) fall investigations were thoroughly investigated and completed in accordance with the facility's practice and policy for 2 of 3 residents reviewed for falls (Residents #1 and #2). The deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview and review of facility provided documentation, it was determined that the facility failed to ensure that the Certified Nursing Aide (CNA) received a performance review for five (5) of five (5) CNA files reviewed. This deficient practice was evidenced by the following: A review of the facility provided, Licensed annual education, competencies, and performance reviews, dated January 2023 to October 2024, did not reveal performance reviews for the five (5) randomly selected CNAs. On 10/16/24 at 11:24 AM, during an interview with the surveyor, the Human Resources Director (HRD) stated that the Director of Nursing (DON) was in-charge of education, competencies (lecture, training, pre and posttests) and performance reviews for the nursing staff. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to assure that the required staff attended the quarterly Quality Assurance (QA) meetings. This was identified for 3 of 3 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: The surveyor requested to review the QA meeting sign in sheets for the last 3 quarters dated September 5, 2024, July 16, 2024 and May 23, 2024, upon entrance. A review of the QA meetings sign in sheets revealed that the Infection Control Preventionist (IP) had not been in attendance for the three meetings. On 10/15/24 at 11:40 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the IP was not able to attend the QAPI meetings since that staff member works the evening shift (3-11) and is also the nursing supervisor. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the prior year's State of New Jersey (State) inspection results and post the location of those results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following. The surveyor conducted a group meeting on 10/16/24 at 11:00 AM with 6 alert and oriented residents chosen by the facility. Six of 6 residents stated they did not know where to find the State inspection results. The surveyor looked for the most recent State inspection results (8/10/23) on each of the 3 nursing units (LP, SP, HP) on 10/17/24 at 9:00 AM. The LP Nursing Station had a plastic binder holder affixed to the front wall of the station. The binder contained 2017 and 2018 State inspection results. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure staff follow the physician's order for the use of side rails for 1 of 21 residents, (Resident #56) and b.) ensure staff follow the physician's order according to the facility's policies and standards of clinical practice for 1 of 3 nurses, Licensed Practical Nurse (LPN)), for 1 of 9 Residents (Resident #252) observed during medication administration. 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 pertinent facility documentation, it was determined that the facility failed to ensure that residents dependent on staff for Activities of Daily Living (ADL) received personal hygiene care in accordance with the facility policy. This deficient practice was identified for 1 of 1 resident (Resident #22,) reviewed for ADL care and was evidenced by the following: On 10/10/24 at 10:49 AM, the surveyor observed Resident #22 in bed with the Certified Nursing Assistant (CNA) assigned to their care in their room. The surveyor observed the resident's fingernails to be long, jagged and soiled with a brown substance underneath. Resident #22 stated that he/she would like to go to the salon to have their nails cleaned and manicured. The CNA told the resident she would see if the resident was on the list to go to the salon. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order and failed to ensure respiratory nasal cannula tubing was stored in accordance with infection control measures for 1 of 1 resident reviewed for Respiratory therapy, Resident #22. 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, and record review, it was determined that the facility failed to consistently provide pharmaceutical services in accordance with professional standards to ensure a.) reconciliation and accountability of dispensed and administered controlled dangerous substance (narcotic medications, with high potential for abuse and are tracked with detail) to Resident #19, and discrepancies were identified, for the narcotic stored in the medication cart located on the high side of the LP unit, and b.) reconciliation of Controlled Drug Inventory Record (CDIR; shift to shift log, a count/signature of two (2) nurses for narcotic accountability) were consistently signed/completed for the medication cart located on the B-side of the HP unit. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring proper hand hygiene was performed prior to dining services and hand wipes were used and discarded appropriately . This deficient practice was identified on 1 of 3 nursing units (HP) and evidenced by the following: On 10/10/24 at 12:00 PM, the surveyor observed twenty residents seated in the HP front dining room preparing for their lunch meal. On 10/10/24 at 12:20 PM, the surveyor observed the Certified Nursing Assistant (CNA) assisted the residents with their hand hygiene. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to promote the dignity and independence for three of three residents (Resident (R)88, R47 and R9) reviewed for dining in a total sample of 24 residents. Specifically, R88 and R47 were observed being assisted with feeding by staff standing throughout the meal service. Additionally, R9 was observed to sit and wait for lunch to be served while other residents were already served.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to provide meals at regular times. Specifically, the facility failed to deliver resident meals in a timely manner, for three of three (Residents (R)24, R42, and R62) reviewed for meal service. This had the potential to affect residents receiving room trays, and residents eating in the LP unit's back dining room.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to keep the food storage bins clean and failed to ensure opened food was dated, labeled, and sealed. This had the potential to affect 91 of 93 residents who resided in the facility and consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure four residents (Residents (R)24, R37, R42 and R56) of 24 sample residents had their call lights within reach when in their rooms, specifically when they were in their beds. This failure created the potential for the residents not to have a means of directly contacting caregivers.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to provide a baseline care plan within 48 hours of admission for one resident (Resident (R)98) of one resident reviewed for base line care plans out of 24 sampled residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide timely morning (AM) care for one of one resident (Resident (R)40) reviewed for Activities of Daily Living (ADLs) out of a total sample of 24 residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Medication errors were noted for two out of 25 medications observed, affecting two residents (Resident (R)70 and R12) for a medication error rate of 8%. Findings Include: 1. Review of R70's annual MDS with an ARD of 06/12/23, found in the EMR under the MDS tab, revealed R70 was admitted to the facility on [DATE] and had a BIMS score of 13 out of 15, which indicated R70 was not cognitively impaired. The MDS also indicated R70 had a diagnosis of but not limited to hypertension, diabetes mellitus, stroke, and depression. Review of R70's Physician Orders, dated 08/04/23, found in the EMR under the Orders tab, revealed Carbamide Peroxide 0.65% ear drops Instill 5 drops in each ear TID (9:00 AM, 1:00 PM, and 5:00 PM) for 5 days. [...]

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure two of two medication carts on the secured unit were locked while unattended. This had the potential to affect two (Resident (R)3 and R37) of 16 residents who were in the dining room on the secured unit while the med carts were observed unlocked. R3 and R37 could ambulate/self-propel themselves while in the dining room.