Glen Ridge Health Campus

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of manufacturer's information, the facility failed to ensure the medication error rate was less than 5 percent (%). The facility had 4 medication errors out of 26 total opportunities, affecting 2 of 3 residents reviewed during the medication administration task (Resident (R)54 and R58), which resulted in a medication (med) error rate of 15.38 %.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid (CMS) Long-Term Care Facility, Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) Assessment for 1 of 16 sampled residents (Resident (R)54).

Inspectors wroteBased on interview, record review, and facility standard operating procedure review, the facility failed to obtain orders for supplemental oxygen use for 1 of 1 resident reviewed for respiratory care, out of the 16 total sampled residents (Resident (R)54).

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to protect a resident's right to be free from mental abuse perpetrated by a staff member for 1 of 2 sampled residents reviewed for abuse, out of the total sample of 16.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to submit an initial report of an allegation of staff-to-resident abuse to the State Survey Agency (SSA) within two hours for 1 of 2 sampled residents reviewed for abuse (Resident (R)214).

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined, the facility failed to ensure personal privacy for one (1) of six (6) sampled residents reviewed for dignity (Resident #32). Observation revealed staff obtained Resident #32's blood glucose level and administered insulin in the resident's abdomen while he/she was seated at a table in a common area with five (5) other residents.

Inspectors wroteBased on interview, record review, and review of facility documents and policy, it was determined the facility failed to ensure resolution of a grievance for one (1) of twenty (20) sampled residents, (Resident #9). Interview with staff revealed they were aware Resident #9 did not sleep well at night due to his/her roommate's yelling/screaming out, and reported everyone knew about that information. However, the facility failed to make prompt efforts to resolve the resident's complaint/grievance and ensure he/she received the care and treatment necessary to achieve adequate rest/sleep at night.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to implement the bowel protocol in accordance with physician's orders for one (1) of one (1) sampled resident for bowel management (Resident #213) out of the total sample of twenty (20) residents. The facility failed to implement the bowel protocol for Resident #213, when the resident exceeded 72 hours with no bowel movement (BM).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary foot care for one (1) of seven (7) residents sampled for activities of daily living (ADLs), (Resident #3). Observation revealed Resident #3's toenails extended half an inch to one (1) inch beyond the tips of his/her toes.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to assist one (1) of seven (7) residents sampled for review of activities of daily living (ADL) care, (Resident #3). Observation revealed Resident #3's feet were dry with a buildup of black, dry, and flaky skin between and under the toes. Additionally, the skin on the resident's heels was also observed as dry and flaky with a buildup of callused skin on the right heel.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and implement appropriate safety interventions for one (1) of six (6) sampled residents (Resident #213) reviewed for accidents/hazards out of the total sample of twenty (20) residents. The facility failed to identify loose screws in a round metal ring that covered the grab bar in Resident #213's shower which contributed to the resident's fall on 02/09/2024.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to provide pharmaceutical services to meet the needs of one (1) of six (6) sampled residents reviewed for pharmacy services (Resident #209). The facility admitted Resident #209 on 09/25/2023; however, failed to ensure the resident's medications were ordered from the pharmacy until the following day, on 09/26/2023. Consequently, Resident #209 missed ten (10) doses of his/her routine medications on 09/26/2023, because the medications were not available.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure staff implemented the care plan to prevent falls for one (1) of three (3) sampled residents, Resident #204. Record review revealed the facility determined Resident #204 required one (1) staff assistance for transfers and toileting and was care planned for staff to assist with transfers and toileting. However, on [DATE] at 4:00 AM, staff found the resident on the floor close to the bathroom, on his/her right side and back, when the resident attempted to go the bathroom unassisted. On [DATE] at 3:15 AM, staff found the resident on the floor when he/she attempted to go to the bathroom unassisted. The resident was sent to the hospital for treatment of injuries and later expired. [...]

Inspectors wroteBased on interview, record review, facility policy review, and review of the facility's investigation, it was determined the facility failed to have an effective system in place to provide adequate supervision to prevent accidents and injuries for one (1) of three (3) sampled residents, Resident #204. Record review revealed on [DATE] at 4:00 AM, Resident #204 acquired skin tears on his/her right middle and ring fingers and a skin tear along his/her upper back related to an unwitnessed fall. The night shift nurse found Resident #204 in her/his room by the bathroom. Per interviews, staff was aware the resident did not always use the call light to request assistance; however, after the fall, the resident's supervision was not increased and on [DATE], the resident fell again. [...]

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to ensure staff accurately coded the Minimum Data Set (MDS) assessment for one (1) of five (5) sampled residents, Resident #41, related to falls. Resident #41 sustained a fall prior to admission and had a fall in the facility; however, the falls were not identified on the MDS.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection control program to help prevent the transmission of disease and infection for one (1) of fourteen (14) sampled residents, Resident #16. Observation revealed Licensed Practical Nurse (LPN) #3 and Certified Resident Care Associate (CRCA) #1 exited Resident #16's isolation room without washing their hands. In addition, the Activities Director walked into Resident #16's isolation room without donning Personal Protective Equipment (PPE) and left without washing her hands, and entered another resident's room.