Family of Caring Healthcare at Ridgewood

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified in 1 of 4 units, 3 of 3 Residents rooms, (South Ground unit: Residents Rooms #118, #119, and #122), and 1 of 1 activity room during environment tour. This deficient practice was evidenced by the following: 1. On 4/29/25 at 10:48 AM, Surveyor #1 (S#1) and the Minimum Data Set/Registered Nurse (MDS/RN) went inside Resident room [ROOM NUMBER] (RR#122), and two residents were inside the room. Both S#1 and the MDS/RN observed the residents' toilet room that the toilet bowl with a blackish substance. S#1 asked the MDS/RN what were those blackish substance and should that be there, and the MDS/RN did not respond. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to; a.) clarify the physicians' orders for 2 of 21 residents, (Resident #27 and Resident #55), b.) adequately monitor target behavior of a resident with an order for antipsychotic medication (med), for 1 of 5 residents, (Resident #187), reviewed for unnecessary medications, and c.) follow the physician order for 1 of 3 residents, (Resident #335), observed during med administration, according to the standard 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 interview, record review, and review of other pertinent facility provided documentation, the facility failed to a.) review and evaluate the resident's condition and total program of care; b.) ensure that the Advance Practice Nurse (APN) accurately documented the resident's medications or plan of care at the time of the visit; and c.) ensure a resident's diagnoses were accurate. This deficient practice was identified for for 2 of 21 residents reviewed (Residents #27 and #71), and the evidence was as follows: 1. On 4/29/25 at 10:48 AM, during an initial tour, Surveyor #1 (S#1) and the Minimum Data Set/Registered Nurse (MDS/RN) observed Resident #27 inside their room seated in a chair. S#1 reviewed the medical records of Resident #27. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly label medication in 1 of 4 medication carts (med cart) inspected according to facility's policy and standard of clinical practice. 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; 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, record review, and review of other pertinent documents, it was determined that the facility failed to maintain medical records that were accurate for 1 of 21 residents reviewed (Resident #185). This deficient practice was evidenced by the following: On 5/1/25 at 10:14 AM, the surveyor reviewed the closed hybrid (paper and electronic) medical record of Resident #185. A review of the admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but not limited to ulcerative colitis (a chronic inflammatory bowel disease (IBD) that causes inflammation and ulcers in the lining of the large intestine (colon) and rectum) and fracture of right lower leg (a break or crack in one of the bones in the leg). [...]

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 one (1) of 18 residents, (Resident #39) for a total of eight (8) quarters reviewed for oral/dental status and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual dated October 2019, page L-1 (423), Item Rationale, Health-related Quality of Life, included that poor oral health has a negative impact on quality of life, overall health, and nutritional status. [...]

Inspectors wroteBased on the interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to obtain an order for discharge and document a discharge summary which included a recapitulation of the resident's stay and a final summary of the resident's status for one (1) of three (3) closed records reviewed for discharge (Resident #76). This deficient practice was evidenced by the following: On 02/24/23 at 11:29 AM, the surveyor reviewed the closed medical record for Resident #76 and revealed the following: The admission Record (or face sheet; [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to maintain the necessary respiratory care and services for residents who were receiving oxygen and nebulizer (neb) treatments according to standards of practice. This deficient practice was identified for two (2) of five (5) residents (Resident #8 and #32) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 02/16/23 at 11:27 AM, the surveyor observed Resident #8 lying in bed with oxygen ongoing at three liters per minute (3 LPM) via nasal cannula (NC) that was attached to an oxygen concentrator (a medical device used for delivering oxygen). The oxygen NC was not dated. The surveyor asked Resident #8 if the NC had been changed weekly. Resident #8 did not know if the NC was being changed weekly. [...]

Inspectors wroteBased on observation, interview, and a review of the pertinent facility provided documents, it was determined that the facility failed to ensure that the staff complied with nursing aide requirements with federal and state guidance prior to providing direct care to the resident. This deficient practice was identified for one (1) of two (2) none Certified Nursing Aides observed during an initial tour as evidenced by the following: On 02/16/23 at 10:16 AM the surveyor observed a Hospitality Aide (HA) performing resident care on Resident #27. The HA toileted the resident and provided direct care to the resident. A review of the 02/16/23 staffing that was provided by the Staffing Coordinator (SC) revealed that the HA was on the schedule and listed as a Certified Nursing Assistant (CNA) for South Ground. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to accurately post the nurse staffing information on two (2) of nine (9) days during the survey period in a place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 02/16/23 at 10:00 AM, the surveyor observed the facility Resident Care Staffing Report (RCSR) dated 02/16/23 posted in a plastic cover attached to the front reception desk. The RCSR revealed that there was a current resident census (total number of residents) of 88 and there were 11 certified nursing aides (CNA) with 7.5 actual hours worked in the facility for the 7 AM to 3 PM shift which calculated to one (1) CNA to eight (8) residents for the staff to resident ratio. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to assure that a medication (Midodrine) was administered according to a physician's order for one (1) of five (5) residents (Resident #69) reviewed for medication management. 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 documents, it was determined that the facility failed to notify the physician or nurse practitioner of the results that fall outside the clinical reference ranges (abnormal results) in accordance with facility policies and procedures for notification of a practitioner for one (1) of 18 residents reviewed, (Resident #46). This deficient practice was evidenced by the following: On 02/17/23 at 08:29 AM, the surveyor observed Resident #46 laying on the bed with their eyes closed. There was a nebulizer (neb) machine on top of the nightstand table. On 02/21/23 at 9:54 AM, the surveyor observed the resident seated on the bed. There was no neb machine on top of the nightstand table. On 02/21/23 at 10:08 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the resident's neb machine. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to: a) perform hand hygiene appropriately for two (Recreation Assistant and Licensed Practical Nurse) of eleven staff and b) properly use PPE (personal protective equipment) for one (Recreation Assistant) of eight staff observed in accordance with the Centers for Disease Control and Prevention (CDC) guidelines and facility policy. This deficient practice was evidenced by the following: According to the U.S. [...]

Inspectors wroteBased on the interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) a) completed the required training in infection prevention and control prior to assuming the position of an IP for one (1) of three (3) staff, b) met the required at least part-time position for one (1) of three (3) staff, and c) qualified for primary professional training requirement for one (1) of three (3) staff in accordance with the facility policy and Centers for Medicare and Medicaid Services (CMS) and New Jersey (NJ) guidelines. This deficient practice was evidenced by the following: According to the NJ Executive Directive 21-012 (revised 12/22/22) included ii. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow a physician's order and document the amount of a supplement intake for 1 of 18 residents (Resident #43) for three months, according to the standards of clinical practice. 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 review of pertinent facility documents, it was determined that the facility failed to: a) ensure proper use of personal protective equipment (PPE) for 3 of 7 staff; b) perform handwashing appropriately for 1 of 8 staff; and, c) ensure that workers were knowledgeable of the cleaning chemicals and process used in the workplace for 1 of 3 staff in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: According to the U.S. [...]