Health Center at Bloomingdale

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 2 (two) of 21 residents (Resident #2 and #6) during the review of resident assessment. This deficient practice was evidenced by the following: The MDS is a comprehensive tool, a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. [...]

Inspectors wroteRepeat Deficiency Based 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 two (2) of 21 residents, (Residents #15 and #114) reviewed for MDS accuracy, and was evidenced by the following: 1. The surveyor observed Resident #15 on 8/22/2025 at 12:00 pm eating lunch in the unit dining room. An observation of the resident’s room on 8/25/25 at 9:35 am revealed signage on the door leading to the room indicating the resident was on Enhanced Barrier Precautions (EBP). A plastic bin was placed at the entrance to the room in the hallway containing personal protective equipment (PPE). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan (CP) for a resident on long-term use of insulin medication. This deficient practice was identified in 1 (one) of the 21 residents (Resident#6) reviewed for CP.This deficient practice was evidenced by the following: On 8/22/2025 11:00 AM, the surveyor observed Resident #6 sitting in bed awake, alert, and able to answer the surveyor's inquiry. Resident #6 confirmed to the surveyor that they have had diabetes and are taking insulin injections. On 8/25/2025 at 1:16 PM, the surveyor reviewed the electronic Medical Record (eMR)/hybrid medical record (paper and electronic) of Resident #6, which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that the resident's primary physician accurately dated their physician progress notes (PPN) during their visit to ensure the resident's current medical regimen was up to date. This deficient practice was observed for 3 of 21 residents (Residents #3, #6, and #10). This deficient practice was evidenced by the following: 1. On 8/22/2025 at 10:24 AM, the surveyor observed Resident #3 sitting in a wheelchair in the activity room. On 8/27/2025 at 1:46 PM, the surveyor reviewed the electronic Medical Record (eMR)/hybrid medical record (paper and electronic) of Resident #3, which revealed the following: [...]

Inspectors wroteRepeat Deficiency Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications (meds) were administered without error of 5% or more. During the morning med administration observation on 8/26/25, the surveyor observed 1 (one) nurse administering meds to 1 resident (Resident #115). There were 25 opportunities, and 3 errors resulting in a total error rate of 12%.The deficient practices were evidenced by the following: On 8/26/25 at 8:24 AM, during the morning med administration pass (med pass), the surveyor observed a Licensed Practical Nurse (LPN) preparing to administer meds to Resident #115. At that time, the surveyor observed that the LPN prepared and administered crushed meds to Resident #115 that included the following: - two tablets (tabs) of ascorbic acid 500 mg. [...]

Inspectors wroteCOMPLAINT # NJ00172263 Based on interview, record review, and review of other pertinent facility documents on 3/25/24, it was determined that the facility failed to consistently complete the dialysis communication form and maintain a residents dialysis communication record. This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for dialysis. This deficient practice is evidenced by the following: 1. According to the facility admission RECORD Resident #1 was admitted with diagnosis that included but were not limited to: End Stage Renal Disease. The Minimum Data Set (MDS) an assessment tool dated 9/15/23, Resident #1's cognitions were intact and required assistance during Activities of Daily Living (ADL). The care plan (CP), undated, revealed that Resident #1 had Seizure Disorder and Dysphagia. [...]

Inspectors wroteBased on the interview and review of pertinent facility documentation, it was determined that the facility failed to complete a thorough investigation for six (6) of six (6) fall incidents of Resident #80 reviewed for fall investigations. This deficient practice was evidenced by the following: On 02/14/24 at 10:54 AM, the surveyor observed Resident #80, awake, and laying on a low bed with two floormats in use. On 02/15/24 at 8:18 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) for the resident's fall investigations for the last six months. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #80 as follows: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to store potentially hazardous foods in a manner to prevent food borne illness as evidenced by the following: On 02/14/24 at 9:55, in the presence of the Food Service Manager (FSM) the surveyor observed the following: 1. In the freezer, the surveyor observed a pack of opened manufactured Cheese Omelet a bag of crunchy fish fillets, and a bag of tot potatoes. All were unlabeled and not dated with expiration or open dates. The FSM manager was unable to say when the package was received, opened, or the expiration date. 2. The Manual counter attached can opener and holder and blade unit was unclean with wipeable by the FSM with sticky brown substance and crumbs. The FSM acknowledged that it needed to be cleaned. On 02/15/24 at 11:34 AM, the surveyor interviewed the FSM. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices for performing hand hygiene to decrease the possibility of spreading infection. This deficient practice was observed during dining observation with four (4) of four (4) facility staff in one (1) of three (3) dining areas, in accordance with the facility's practice, policies, and Centers for Disease Control and Prevention (CDC) guidelines for infection control. This deficient practice was evidenced by the following: According to the CDC Hand Hygiene in Healthcare Settings, Hand Hygiene Guidance, last reviewed on January 30, 2020, included that Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: [...]

Inspectors wroteComplaint# NJ169589 Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a) ensure written grievance decisions met documentation requirements and b) maintain evidence of the result of all grievances for no less than three (3) years from the date the grievance decision was issued according to facility practice and policy. This deficient practice was identified for one (1) of five (5) residents (Resident #352) reviewed for complaints. This deficient practice was evidenced by the following: On 02/16/24 at 10:34 AM, the surveyor requested for all the reportable and grievances for the last six months for Resident #352 from the Licensed Nursing Home Administrator (LNHA). The surveyor reviewed the facility provided grievance log for November 2023 that included Resident #352. [...]

Inspectors wroteBased on the interview, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of the 23 residents reviewed, Resident #80. This deficient practice was evidenced by the following: On 02/14/24 at 10:54 AM, the surveyor observed Resident #80, awake, and laying on a low bed with two floormats in use. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #80 as follows: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a) follow the weekly skin assessments schedule and documentation of the weekly skin assessment according to the order and facility policy for one (1) of 20 residents, (Resident #89) reviewed for quality of care and b) ensure appropriate care and services was provided to a resident with regard to vision for one (1) of two (2) residents, Resident #71, reviewed for visual impairment. This deficient practice was evidenced by the following: 1. On 02/14/24 at 11:21 AM, the surveyor observed the resident out of bed (OOB) in a wheelchair with the call bell within reach. The resident was actively watching TV (television) and had no complaints of the food or the staff. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to ensure that the left elbow splint was consistently applied according to the physician's order. This deficient practice was identified for one (1) of three (3) residents reviewed for the limited range of motion (ROM), Resident #80. This deficient practice was evidenced by the following: On 02/14/24 at 10:54 AM, the surveyor observed Resident #80, awake and laying on a low bed. The resident did not have a splint in use at the time of observation. There was a splint on top of the nightstand table. On 02/15/24 at 01:07 PM, the surveyor and the Licensed Practical Nurse (LPN) went inside the resident's room. The LPN informed the surveyor that Resident #80 was in the activity in the dining area. [...]

Inspectors wroteBased on observations, interviews, and review of other pertinent facility provided documentation, the facility failed to a) ensure a root cause analysis conclusion was included routinely in a resident's fall investigation/incident report, b) implement the resident's care plan fall intervention, and c) ensure that fall assessments were done according to facility's practice and policy, and standard of practice, for one (1) of three (3) residents reviewed for falls (Resident #80). 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 consistently document catheter urinary output according to the physician orders. This deficient practice was identified for one (1) of two (2) residents reviewed for urinary catheters (Resident #13) and was evidenced by the following. On 02/14/24 at 10:45 AM, during the initial tour, the surveyor did not observe the resident in the room. The resident's bed was at a high position and the bedside table was at the foot of the resident's bed. On the side of the bed was an intravenous pump for Vancomycin (antibiotic) that appeared to have been administered completely. At 02:14 PM, the surveyor observed the resident in the rehabilitation room with one of the rehabilitation staff. Resident #13 greeted the surveyor. [...]

Inspectors wroteBased on observations, interviews, records review, and review of other facility documentation, it was determined that the facility failed to: a.) monitor the resident's nutritional supplement intake, b.) implement and monitor weekly weights, and c.) ensure the accuracy of a resident's weight who had a history of weight fluctuation. This deficient practice was identified for one (1) of three (3) residents reviewed for nutrition (Resident #45) and was evidenced by the following: Reference: American Thyroid Association A review of the brochure of Thyroid Function Test included, -A high TSH (thyroid stimulating hormone) level indicates that the thyroid gland is not making enough thyroid hormone (primary hypothyroidism). -TSH level is low, usually indicates that the thyroid is producing too much thyroid hormone (hyperthyroidism). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) maintain consistent documentation of accounting of backup controlled substance inventory, b) ensure accurate accounting and reconciliation of backup controlled substances, and c) ensure that the facility management was notified of the identified discrepancies in the backup controlled substances according to the facility's practice, policy, and standard of practice. This deficient practice was identified in one (1) of two (2) medication storage rooms during the medication storage review. 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 ensure that all medications were administered without error of 5% or more. During the medication observation conducted on 02/16/23, the two (2) surveyors observed four (4) nurses administer medications to five (5) residents. There were 32 opportunities, and two errors were observed which resulted in a medication error rate of 6.25%. This deficient practice was identified for two (2) of six (6) residents (Resident #22 and #354), that was administered by two (2) of four (4) nurses. This deficient practice was evidenced by the following: A review of the manufacturer's specifications for Cosopt PF under section 17.4 Handing the Single-Use Container included: COSOPT PF is a sterile solution that does not contain a preservative. [...]

Inspectors wroteBased on interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice for not following physician orders for 1 of 23 residents (Resident #70) which occurred over a three month period and failed to document in the Electronic Treatment Administration Record (ETAR) for 2 of 23 residents (Resident #88 and #61) reviewed. The 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, and record review, it was determined that the facility failed to respond to the consultant pharmacist recommendations for 1 of 21 residents (Resident #70) reviewed. This deficient practice continued over four months and was evidenced by the following: According to the November 2021 Clinical Physicians Order sheet Resident #70 had an order dated 2/25/2020 for Midodrine HCl 10 mg two times daily with parameters to hold the medication when the systolic blood pressure (SBP) is above 120. The surveyor reviewed the August 2021, September 2021, and October 2021 Electronic Medication Administration Record that revealed the nurses administered the Midodrine HCl 10 mg to Resident #70 when the SBP was above 120 on 21 occasions. The surveyor reviewed the Consultant Pharmacist Medication Regimen Review report for June 2021, July 2021, August 2021, and September 2021. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 1 of 5 medication carts and 1 of 2 emergency boxes that were inspected. The expired medication in the emergency boxes continued for four months and was evidenced by the following: On [DATE] at 11:11 AM, the surveyor inspected the 2nd floor South-side medication cart in the presence of a Licensed Practical Nurse (LPN #1). The surveyor observed an opened bottle of Blood Glucose control solution with an opened date of [DATE] that was expired (90-day expiration date). The surveyor interviewed LPN #1 who stated that the opened bottle of Blood Glucose control solution was expired and should have been removed from the medication cart. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) an assessment tool for 1 of 23 residents reviewed for MDS accuracy (Resident #28). This deficient practice was evidenced by the following: The surveyor observed Resident #28 in bed with eyes open on 11/10/21 at 11:15 AM. On 11/12/21 at 11:19 AM, the surveyor completed a review of the electronic medical record. The admission Record revealed that the resident was admitted to the facility with diagnoses that included but were not limited to dementia, primary hypertension, osteoarthritis, and chronic kidney disease. The 9/5/2021 Annual MDS indicated that the resident had moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to implement a comprehensive care plan for Resident #28, 1 of 23 residents reviewed. This deficient practice was evidenced by the following: On 11/10/21 at 11:15 AM, the surveyor observed Resident #28 in bed with eyes open. A nasal cannula was observed in the resident's nose. The oxygen concentrator was set to two liters of oxygen per minute. On 11/12/21 at 11:19 AM, the surveyor reviewed the medical record for Resident #28: The admission Record revealed that the resident was admitted to the facility with diagnoses that included but were not limited to primary hypertension. The 9/5/2021Annual MDS indicated that the resident had moderate cognitive impairment and was currently using oxygen therapy. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to update and/or revise care plans for 3 of 23 residents reviewed, Resident # 9, Resident # 61, and Resident # 96. The deficient practice was evidenced by the following: 1. The surveyor reviewed an investigation for a fall Resident #9 had. The fall was on 2/10/21. The resident did not sustain any injuries. The investigation determined that the resident fell out of bed while reaching for their cell phone that had fallen on the floor. The investigation of the fall indicated that the Interdisciplinary Team agreed to add the following interventions to the care plan to prevent future falls; a longer phone charger cord and a side rail pouch for the resident to keep their cell phone. The surveyor asked the Director of Nursing (DON) for all of the active care plans for the resident. [...]

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident received the necessary supervision for smoking and storage of smoking materials. The deficient practice was identified for 1 resident (Resident #42) of 2 reviewed for smoking and is evidenced by the following: The surveyor interviewed Resident #42 on 11/10/21 at 10:27 AM. The resident stated they independently smoked and held their own cigarettes and lighter. The resident further stated they were able to go outside at any time unsupervised to smoke. The resident stated their smoking materials were kept in their pocket when not in use. The surveyor observed the resident smoking unsupervised on 11/10/21 at 11:04 AM and on 11/15/21 at 11:07 AM. A review of the medical record revealed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to restrain employee hair in the kitchen. This deficient practice was evidenced by the following: On 11/10/21 at 9:37 AM, in the presence of the Director of Nutritional Services (DNS), the surveyor observed the following: In the food preparation area, the surveyor observed the DNS without a hair net over his hair. The surveyor also observed a Food Service Worker in the food preparation area with a hair net on her head yet, her bangs were not fully restrained inside the hair net. The DNS agreed that the hair nets should have been worn appropriately according to facility's policy. The surveyor reviewed the facility's policy titled, Food Preparation and Service dated April 2021. The policy indicated that food and nutrition services staff wear hair restraints so that hair does not contact the food. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection for: a.) hand hygiene during food and dish handling and b.) failure to properly don (put on) surgical and respirator masks. The deficient practices were evidenced by the following: 1. On 11/10/21 at 9:37 AM, the surveyor observed the Director of Nutritional Services (DNS) in the food preparation area of the kitchen with his respirator mask covering his mouth and not covering his nose. The DNS stated that he had just arrived for work and should have worn his mask appropriately. 2. In the food preparation area, the surveyor observed Food Service Worker (FSW) #1 with gloved hands adjust her hair net on her head, remove her gloves and immediately don a new pair of gloves with no hand hygiene performed. 3. [...]